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PRACTICAL CLINICAL LESSONS 



ox 



SYPHILIS 



AtfD THE 



GENITOURINARY DISEASES 



BY 

FESSENDEN N. OTIS, M.D. 

CLINICAL PROFESSOR OF GENITO- URINARY DISEASES IN THE COLLEGE OF PHYSICIANS 

AND SURGEONS, NET YORK; SURGEON TO CHARITY HOSPITAL; CONSULTING 

SURGEON TO ST. ELIZABETH'S HOSPITAL, TO THE NEW YORK SKIN AND 

CANCER HOSPITAL, AND TO THE COLORED ORPHAN ASYLUM ; 

FELLOW OF THE NEW YORK ACADEMY OF MEDICINE ; 

MEMBER OF THE BRITISH MEDICAL ASSOCIATION, 

ETC. 








NEW YORK 

BERMINGHAM & CO. 

1883 



Copyright, 1883, by Bermingham & Co. 



TO 

WILLARD PARKER, M.D., LL.D. 

EMERITUS PROFESSOR OF SURGERY IN THE COLLEGE OF 
PHYSICIANS AND SURGEONS, 
NEW ■ YORK. , 

RENOWNED AS A TEACHER, DISTINGUISHED AS A SURGEON, 

EMINENT AS A CITIZEN, UNIVERSALLY BELOVED 

FOR HIS NOBLE NATURE AND HIS 

GENEROUS ACTS, 



£t)is toork, 



WITH HIS CONSENT, IS GRATEFULLY AND AFFECTIONATELY 

DEDICATED BY ONE, AMONG THE MANY, OF HIS 

MEDICAL BRETHREN, WHO OWE TO HIM — 

NOW FULL OF YEARS AND HONORS 

— THE GREATEST MEASURE 

OF THEIR 

PROFESSIONAL SUCCESS. 



PREFACE. 



For a number of years it has been my custom, to dis- 
tribute, from time to time, to the students of the Col- 
lege of Physicians and Surgeons, short papers, of a few 
pages each, which were entitled " Class-room Lessons" 
In these I endeavored to embody important principles, 
in the study of syphilis and the genito-urinary diseases. 
The lessons were intended to prevent errors, arising 
from inattention, or from misunderstanding of the state- 
ments made during the lectures in the college, and at 
Charity Hospital. This was rendered especially neces- 
sary, from the fact that my own views, on certain im- 
portant points, differed, essentially, from those embodied 
in the text-books in general use. In the first place, on 
the subject of syphilis : I had been unable to accept the 
statements of all authorities, that it was a mysterious, 
instantaneous, poisoning of the organism, in defiance of 
all known physiological and pathological laws. A care- 
ful study of the matter, in connection with modern dis- 
coveries in physiology and pathology, had convinced 
me, that an explanation of all the lesions and manifesta- 
tions of syphilis was possible, through known physiologi- 
cal and pathological processes, and that, the then uni- 
versally accepted view of the supernatural advent and 
behavior of syphilis, was incorrect. This position was 
taken, in my lectures in the college, in 1868. In 1870, it 
was presented to the medical profession, in a paper be- 
fore the Medical Society of the county of New York, 
and was followed by another paper, on the same subject, 
in 1871. Up to that time, no systematic effort had been 
made to explain the various manifestations of syphilis, 
on a scientific basis. In 1866, Beale had claimed, from 
his investigations of variola and the cattle disease, the 



6 PREFACE. 

presence of a germinal cell, as a cause of syphilis. Bei- 
siadecki, of Krakow, had published, in 1867, the results 
of his microscopical examination of infecting- chancre, 
in which he showed a localized proliferation of cell ele- 
ments in the lymphatic vessels, as a starting-point in 
syphilis, and claimed that this might afford an explana- 
tion, through which the general infection might be ex- 
plained. I took up the matter at this point, and through 
the results of pathological and histological researches of 
accepted authorities in pathology and histology, in other 
fields, succeeded, as I believed, in explaining the various 
syphilitic phenomena throughout the entire course of 
the disease. A review of my papers, in the London 
Lancet of Nov. 9th, 1872, concluded with the statement 
that " these new views on the physiology of syphilitic 
infection are not based upon the results of any experi- 
ments or new facts, or on the unravelling of observa- 
tions. They consist mainly of deductions drawn from 
a close and elaborate reasoning on the acknowledged 
features of syphilis in connection with the latest doc- 
trines and hypotheses of certain pathological teachers." 
Starting with the disease-germ, derived from the de- 
graded human germinal cell of Beale, supported by the 
microscopic examinations of Beisiadecki and Verson, 
as to the proliferation of new cell material at the site of 
syphilitic inoculation, and extending only in the line 
lymph channels ; supported still farther by the clinical 
facts, in regard to gradual implication of lymph vessels 
and glands, by the known physiological processes in 
health, and under the influence of syphilitic infection, 
and also through the concurring testimony of such his- 
tological and pathological authorities as Chaveau, 
Beale, Schweiggerseidel, Strieker, Kolliker, Teichman, 
Kohn, Conhiem, Beisiadecki, and others, I was enabled 
to present a reasonable explanation of the course of 
syphilis, from its inception to its termination. It was 
scarcely to be expected, that such a radical departure 
from the views of the text-books, would be received 
without discussion ; but the position taken was so 
amply supported by all known pysiological and patho- 
logical facts, that no opposing arguments were offered. 



PREFACE. 7 

The first authoritative publication in America which 
followed, practically adopted and supported the new 
views thus: (Bumstead and Taylor, N. Y., 1869, 4th 
ed. page 443) " The secretions of syphilitic lesions 
are found to consist of a serous fluid containing numer- 
ous granules or molecules, which are masses of proto- 
plasm or germinal matter holding the contagious properties 
of syphilis. These microscopic bodies are probably 
taken into the circulation by the lymphatics, and con- 
veyed over the body. . . In the secondary period of 
syphilis these cells are very numerous, and the body 
may be covered with papules and tubercles composed of 
them. . . As the disease wanes . . the cells no longer 
have a tendency to reproduction which characterizes 
them in the early stages, but rather degenerate. Hence 
we consider the blood and the secretions in tertiary syphilis 
innocuous." * 

The same views of syphilitic infection were presented 
in the second edition of Berkeley Hill's work, by Berk- 
eley Hill and Arthur Cooper, London, 1881 (p. 75), 
and erroneously attributed to Auspitz of Vienna (al- 
though in a foot-note the reader is referred, for further 
information on the subject, to my work on the Physio- 
logical Pathology and Treatment of Syphilis) thus : 
" The syphilitic virus enters the system by the absorb- 
ents. It first sets up plastic growth in the walls of the 
lymphatic vessels at the part where it is implanted. 
These walls thicken and throw off into their interior, 
cells which contain the virus; as these cells float along 
they convey the virus still further inwards. But the 
infiltration of successive parts of the walls of the lym- 
phatic vessels also conducts the virus inwards. When 
a lymphatic gland is reached, the same proliferating pro- 
cess ensues in the gland, until the cells are sent off 
through the effersent ducts to other glands, and so on to 
the thoracic duct. Thence cells, containing the virus, 
are poured, direct into the circulation, by the veins, and 
are thus quickly carried to the several tissues of the body. 
Then appear the signs of general constitittional infection." 

* Italics my own. 



8 PREFACE. 

Again, in the work of M. Cornil on syphilis (Paris, 1878), 
translated and edited by Profs. Simes and White, of the 
University of Pennsylvania, " with the consent and ap- 
proval of the author," and published in 1882, this same 
view of the mode of syphilitic infection, is extracted from 
my book, preceded by a statement (p. 21) of opinion that, 
" it presents fewer inconsistencies than any of the other the- 
ories /" and on page 23, " that it seems impossible, in the 
light of certain well-known facts, to deny that the syph- 
ilitic poison gains access to the general circulation, chief- 
ly, if not entirely, by the lymphatics ;" and again, page 
25, " the action of mercury in relieving the early symp- 
toms, also becomes intelligible in the light of this the- 
ory, through its influence in hastening destructive met- 
amorphosis and bringing about fatty degeneration ; 
and its general undoubted tendency to relieve tissues 
encumbered with superfluous material. Small doses, 
most naturally, first influence newly-formed immature 
deposits, such as those due to syphilis, and hence the 
advantage of the modern treatment, which avoids sali- 
vation, due to the toxic action of the drug on the healthy 
tissues, and depends upon moderate, long-continued 
doses. The necessity for the use of iodide of potassium, in 
the later stages, with or without mercury, also becomes 
apparent, when it is remembered that iodine is the most 
powerful diffusible stimulant of the function of absorp. 
tion. with which we are acquainted, and that also, it has 
a certain established value, in hastening tissue change, 
especially in unhealthy formations." 

In view of the direct, or implied, approval of my posi- 
tion, by these recent eminent authorities in matters in- 
volving the nature, behavior, and treatment of syphilis, 
it has seemed proper that I should make use of every 
opportunity to advance these views, and to explain, on 
physiological and histological grounds, the various 
points in the diagnosis and treatment of cases of spyhi- 
lis and its sequelae, herewith presented. 

In the second place: Early in my clinical teaching, I 
had found myself unable to accept the conventional 
views, held by authorities on many important points in 
genito-urinary diseases. Especially as to the nature 



PREFACE. 9 

and treatment of gonorrhoea and urethral stricture and 
the normal urethral calibre. As to the latter, I could 
not accept the standard universally taught, but claimed, 
from actual measurements, an individuality for every 
urethra, a proportionate relation, between the size of 
the urethra and the organ in which it is situated, and 
an average calibre, much greater than previously esti- 
mated. I also claimed, contrary to all previous teach- 
ing, a radical cure of urethral stricture, through com- 
plete division. These views, and others growing out of 
them, involving important questions in practice, sup- 
ported by several hundreds of practical examples, de- 
fended in written and in oral debate, against eminent 
authorities in this country and in Europe, made it es- 
pecially necessary for me to have a medium of com- 
munication Avith students, which could not be misin- 
terpreted or misunderstood. With an especial view to 
this, the second volume of this work was suggested. 
No attempt has been made to make it a systematic 
general exposition of genito- urinary diseases. The 
aim has been, chiefly, to present clinical cases, selected 
as typical and practical, which have been subjects of ob- 
servation and study, in my private practice, and in my 
cliniques, and such additional material illustrative of 
important practical points, and my own experience in 
the treatment of such cases, as I could readily com- 
mand. When some learned and not too busy surgeon, 
in gathering, from every quarter, the material for a full 
and systematic treatise on genito-urinary troubles, 
meets the everyday experiences which have been pre- 
sented in the foregoing pages, it is my ambition, that 
some points may be found among them, which will be 
considered worthy of preservation, in more pretentious 
form. Meanwhile, I trust that many surgeons may find, 
in the cases recited, and in the principles and treatment 
advocated, a key which will help to explain much that 
has heretofore appeared obscure, and difficult of man- 
agement. 

F. N. Otis. 

New York, 108 West 34th Street, April 30, 1883. 



CONTENTS. 



LESSON I. 

PAGE 

Nature of Gonorrhoea, Chancroid, and Syphilis — The Initial Lesion 

of Syphilis. 17 



LESSON II. 
The Initial Lesion of Syphilis — {Continued) 27 

LESSON III. 
The Initial Lesion of Syphilis — {Continued). ........>.,... 32 

LESSON IV. 
Syphilis by Hereditary Transmission 42 

LESSON V. 
Early Differential Diagnosis. . . ... .<•........ * 50 

LESSON VI. 
Progress of the Syphilitic Infection ...... 56 

LESSON VII. 
Varieties and Complications of the Initial Lesion of Syphilis 61 



12 CONTENTS. 

LESSON VIII. 

PAGE 

Treatment of the Initial Lesion of Syphilis 66 

LESSON IX. 
Early Constitutional Forms of Syphilis 71 

LESSON X. 
The Treatment of Syphilis in the Acute Stage 81 

LESSON XL 

Clinical Cases, Illustrative of the Various Forms which the Initial 
Lesion may Present, and of the Various Lesions Associated 
with and Following the same 87 

LESSON XII. 
Gangrenous Initial Lesion, or so-called Phagedenic Chancre 97 

LESSON XIII. 

Polymorphous Character of Syphilis in some Cases and Absence of 

Characteristic Lesions in Others 101 

LESSON XIV. 
Mucoid Form of the Initial Lesion 108 

LESSON XV. 
Clinical Case Illustrative of the Results of Treatment 118 

LESSON XVT. 
Results of Treatment — {Continued) 124 



CONTENTS. 13 



LESSON XVII. 

PACT 

Sequelae of Syphilis 128 



LESSON XVIII. 
Non-Contagiousness of the Late Lesions of Syphilis 167 

LESSON XIX. 

Gummy Tumor of Bone, Loss of Substance without Caries — Syphi- 
litic Dactylitis 183 

LESSON XX. 

Syphilitic Sequelae Involving Nasal Bones, Vomer, and Vault of the 

Hard Palate 189 

LESSON XXI. 
Gummy Tumor of Bone, Producing Brain Symptoms 193 

LESSON XXII. 
Late Brain Lesions of Syphilis 199 

LESSON XXIII. 
Syphilis of Infants and Hereditary Syphilis 204 

LESSON XXIV. 
Chancroid: Its Nature and Treatment 207 

LESSON XXV. 
Nature of Chancroid — Continued) 217 



4 CONTENTS. 



LESSON XXVI. 

PAGE 

Does Diagnosis of Chancroid rest upon Character of Lesion or upon 
its Source ? 225 



LESSON XXVII. 
Origin of the Chancroidal Abrasion 229 

LESSON XXVIII. 
Chancroid Modified by Condition 236 

LESSON XXIX. 
Diagnosis and Treatment of Chancroid 240 

LESSON XXX. 

Diagnosis and Treatment of Chancroidal Bubo and Bubonic Chan- 
croid 250 



Remedies and Remedial Agents referred to in Part I. and their 

Application 258 



CONTENTS, PART II. 



LESSON XXXI. page 

Nature of Gonorrhoea 261 

LESSON XXXII. 
Diagnosis of Gonorrhoea 271 

LESSON XXXIII. 
Treatment of Gonorrhoea 282 

LESSON XXXIV. 
Treatment of Gonorrhoea — {Continued) 291 

LESSON XXXV. 
Treatment of Gonorrhoea — {Continued) 300 

LESSON XXXVI. 
Treatment of Gonorrhoea — (Continued) 302 

LESSON XXXVII. 
Treatment of Gonorrhoea — (Continued) 311 

LESSON XXXVIII. 
Treatment of Gonorrhoea— (Continued) 317 

LESSON XXXIX. 
Injections in Gonorrhoea — Gleet 330 



1 6 CONTENTS. 

LESSON XL. page 

Nature of Gleet 336 

LESSON XLI. 
Dependence of Gleet upon Stricture 346 

LESSON XLII. 
Complications of Gonorrhoea 353 

LESSON XLIII. 

Folliculitis — Follicular Ulceration — Urinary Infiltration— External 
Perineal Urethrotomy 366 

LESSON XLIV. 
Urinary Extravasation 373 

LESSON XLV. 

Follicular Sinuses Associated with Urethral Contractions and Reflex 
Neuralgia 380 

LESSON XLVI. 
Epididymitis 390 

LESSON XLVII. 
Prostatitis. 402 

LESSON XLVIII. 
Acute Prostatitis — {Continued) 405 

LESSON XLIX. 
Cystitis 413 

LESSON L. 
Urethral Stricture , 418 

LESSON LI. 
Cause of Stricture 426 



CONTENTS. 17 

LESSON LII. page 

Examination of the Urethra 439 

LESSON LIII. 
Urethrotomy 446 

LESSON LIV. 
Dilating Urethrotomy 457 

LESSON LV. 
Dilating Urethrotomy — {Continued) , 463 

LESSON LVI. 
Spasmodic Stricture, or Urethrismus 470 

LESSON LVII. 
Reflex Irritations throughout the Genito-Urinary Tract 487 

LESSON LVIII. 
Clinical Cases in Illustration of Reflex Irritations 493 

LESSON LIX. 
Clinical Cases in Illustration of Reflex Irritations — {Continued) 499 

LESSON LX. 

Chronic Irritation of Bladder — Neuralgia of Testicles — Irritation of 
Glans — Lack of Virility 505 

LESSON LXI. 
Clinical Cases 512 

LESSON LXII. 
Clinical Cases — {Continued) — Urethrismus 519 

LESSON LXIII. 
Chronic Spasmodic Stricture 526 



1 8 CONTENTS. 

LESSON LXIV. p AGE 

Urethrismus, or Chronic Spasmodic Stricture — {Continued) 538 

LESSON LXV. 
Persistent Recurring Reflex Spasm of the Bladder 541 

LESSON LXVL 
Spasmodic Stricture Simulating Prostatic Enlargement 550 

LESSON LXVII. 

Digital Exploration of the Bladder, as an Aid to Diagnosis in Ob- 
scure Cases 564 

LESSON LXVIII. 

Digital Exploration of the Bladder, as an Aid to Diagnosis in Ob- 
scure Cases — {Continued) 572 



PRACTICAL CLINICAL LESSONS 

ON 

Syphilis and the Genito-Urinary 
Diseases. 



LESSON I. 



Nature of Gonorrhoea — Of Chancroid — Of Syphilis — Infective Princi- 
ple of Syphilis a living Germinal Cell — Its History dating back over 
2000 Years B.C. — Syphilis never of Spontaneous Origin — Always Ac- 
quired from a Human Being suffering with Syphilis — Always Requir- 
ing a Breach of Surface for its Introduction — The Virus of Syphilis 
not an Irritant — The so-called Incubation of Syphilis — Its Practical 
Importance — Admixture of Syphilitic Secretions with Vicious Uterine 
Secretion a common cause of error in Diagnosis — The Initial Lesion 
of Syphilis due to a Localized Cell Proliferation — Not Necessarily 
resulting in an open Lesion — Clinical Cases illustrative of the Devel- 
opment of the Initial Lesion of Syphilis — Treatment by Excision. 

Gentlemen : Through the light of modern teaching 
and experience, we recognize three separate and distinct 
contagious diseases resulting from venereal contact; 
viz., Gonorrhoea, Chancroid, Syphilis. 

ist. Gonorrhoea. — A vicious, non-specific inflamma- 
tion of mucous membrane, characterized by free puru- 
lent secretion without ulceration, chiefly occupying the 
urethra of the male, and the vagina and urethra of the 
female ; exceptionally, the mucous surfaces of the blad- 
der, the eye, the nares, the rectal and buccal cavities ; 
usually, though not necessarily, of venereal origin ; its 
contagious property transferred to sound mucous mem- 
brane without breach of tissue ; its action immediately 
following contact ; its vicious principle incapable of 



f8 PRACTICAL CLINICAL LESSONS ON 

transmission through the general circulation; its occur- 
rence predisposing to subsequent attacks. 

2d. Chancroid. — An acute, contagious ulcer of vene- 
real origin, whose contagious property is incapable 
of contaminating the blood, and hence can never estab- 
lish a constitutional disease, nor be acquired by hered- 
itary transmission ; is characterized by an acute ul- 
cerative action, with free suppuration ; is commonly 
initiated through a breach of surface, but possibly oc- 
curs upon sound tissue ; is usually multiple, and may 
occur repeatedly in the same individual. 

3d. Syphilis. — A specific, contagious, constitutional 
disease, caused by the inoculation, upon any part of the 
human body, of a peculiar principle or contagium called 
the Syphilitic virus, which, after an indefinite period of 
apparent rest, or so-called incubation, produces, at the 
point of inoculation or entrance of the contagium, a. 
characteristic lesion; this followed by another period of 
apparent rest, to which succeeds a group of well-estab- 
lished evidences of the contamination of the general 
system. The characteristic initial lesion is usually soli- 
tary; sluggish, and non-suppurative in its development; 
inoculable with difficulty upon the person bearing it ; 
and as a rule occurs but once in the same individual. 

During the course of clinical lessons which we inaug- 
urate to-day, I propose presenting to you cases of each 
one of the above-named diseases, under a variety of cir- 
cumstances and in different phases of their development. 
However ample the field from whence clinical cases are 
drawn, it is scarcely possible always to secure such a 
choice as will permit the pursuance of a rigidly sys- 
tematic arrangement in their presentation ; I shall, how- 
ever, endeavor to select the cases so as to show you the 
consecutive manifestations or lesions of each disease, as 
far as circumstances will allow. 

To-day I purpose presenting to you a number of 
persons exhibiting one or more phases of the most im- 
portant of the three diseases just mentioned, viz., Syphi- 
lis. This disease is produced by the inoculation of a 
specific virus upon any part of the human body, as pre- 
viously stated. Of the origin, nature or composition of 



SYPHILIS AND THE GENITOURINARY DISEASES. lg 

this virus — vital, physical or chemical — we know prac- 
tically but little. 

The microscope has been brought into requisition by 
distinguished experts through the last quarter of a cen- 
tury, with the expectation of isolating and analyzing 
this so-called virus, but it has eluded all search. Simi- 
lar investigation as to the origin of such contagious dis- 
easss as variola, vaccinia, relapsing fever, and the cattle- 
plague,* have resulted in establishing the fact that a de- 
generated, living, germinal cell contains the infective 
principle or contagium, the so-called virus, through which 
these diseases are communicated. Beale was the first 
to claim that a similar origin would be.found for syphilis, 
but he failed to make the actual discovery. As we pro- 
ceed, however, it will be found that much valuable cir- 
cumstantial evidence will be met, in corroboration of 
Beale's view, and afford a possible interpretation of the 
syphilitic processes in harmony with recognized physio- 
logical and pathological laws. 

Of the history of syphilis so much has been written 
that I have not the time, if I had the inclination, even 
to epitomize the labors of syphilitic historians. I will 
briefly state that books have been written to fix its ori- 
gin at about the fifteenth century, attributing it to the 
effects of excesses in camp at the Siege of Naples, 1494 ; 
others to prove that it originated in America, and was 
carried to Europe by Columbus at about the same 
period ; others, again, and with more reason, assert that 
Moses, the great Jewish lawgiver, knew about it ; and 
the dispute as to the bad eminence of having originated 
syphilis ran high, and higher, involving poets, historians 
and doctors, getting up no end of bad blood, until a re- 
cent time (1863), when a Frenchman, Capt. Dabry by 
name, in translating a very ancient record of Chinese 
medical lore, found this same syphilitic disease thor- 
oughly described in its various stages as existing and 
flourishing over two thousand years before the Chris- 
tian era. 

Its antiquity, and its prevalence to a greater or less 

* Beale on the Nature and Origin of Disease Germs. 



20 PRACTICAL CLINICAL LESSONS ON 

extent in every known country, enable us safely to 
affirm that it has not been from lack of opportunities to 
study the development of syphilis that its constituent 
elements are unfamiliar to us. On the contrary, it has 
been observed with probably more care, with more 
scrupulous nicety, with more laborious and painstaking 
accuracy, than any other disease with which the human 
race are, or ever have been, afflicted. It has not only 
been studied and observed by the keenest, the most eru- 
dite, the most profound practitioners and philosophers 
the medical profession has ever produced, but it has 
been the altar upon which not a few have offered up 
their own bodies as subjects of scientific experiment, 
throwing health — even life itself — into the investigation 
of this foulest and most terrible disease. With the 
great John Hunter heading the list, fully half a score of 
recorded names attest the courageous self-abnegation, 
the grand enthusiasm of our professional brethren in 
the past, whose labors and sufferings furnish us to-day 
with all-important and indisputable facts concerning 
the evolution and development of syphilis. Through 
such earnest investigations, and by extended observa- 
tion of the disease as accidentally acquired, it has been 
accepted — 

i st. That syphilis is never of spontaneous origin; 
that no emanations from natural causes, no admixture 
of diseased conditions, no intermingling of necrotic ele- 
ments, no combination of vicious indulgence, is capable 
of establishing this disease de novo. It has always and 
invariably as a starting-point a human being suffering 
with syphilitic disease. Every syphilitic has contracted 
his syphilis from some antecedent syphilitic — has re- 
ceived into his blood a virus or contagium which has 
circulated in the blood of another suffering with syphi- 
litic disease. 

2d. That for its introduction into the human system 
it requires a breach of surface — a solution of continuity ; 
that it is not absorbed through sound tissues; that it is not 
acquired through inhalation. An entrance of the syphi- 
litic principle always requires a pre-existing artificial 
port of entry. This may be accepted as an unvarying 



SYPHILIS AND THE GENITO-URINARY DISEASES. 21 

rule as regards the acquirement of syphilis. The child 
may contract the disease in utero from the diseased 
blood of the mother. The mother may, it is claimed 
(not proven), become infected through the child in her 
womb, diseased by the influence of the male parent. 
These possible exceptions do not invalidate the spirit 
of the law requiring a breach of continuity for the en- 
trance of the syphilitic virus into the human organism. 

Though the constituent elements of the syphilitic 
virus are not known, this much we do know, viz., that 
the secretion emanating from a certain well-recognized 
kind of sore, — which we call the chancre, or the initial 
lesion of syphilis, — when introduced, by the aid of a lan- 
cet, under the cuticle, or applied to an abraded surface 
anywhere upon a healthy individual, produces, after a 
definite period and with absolute certainty, a lesion 
presenting similar characteristics, and is followed by 
certain other evidences of a contamination of the system 
which cannot be produced by any other known agency. 

We know also that the aforesaid secretion in which 
the virus is hidden, when free from extraneous matters, 
is of a bland, unirritating nature in its local action upon 
living tissues ; that, introduced through an artificial 
puncture or an accidental abrasion, it gives no immedi- 
ate token of its power — it does not in any way interfere 
with the natural, rapid and complete healing of the 
wound. In this particular there exists a radical differ- 
ence between the syphilitic virus and that of the local 
contagious ulcer called the Chancroid, and of the puru- 
lent secretion of a Gonorrhoea ; both of which produce 
an immediate inflammatory action on the site of their 
initiation. 

Given, then, a case in which the syphilitic virus has 
been introduced into the system through a puncture or 
an abrasion and has been succeeded by a complete 
healing of the wounded part, let us consider what fol- 
lows. 

ist. A period of incubation, so called, — a period of 
apparent rest ; a period during which the subject of the 
experiment is entirely free from the least evidence of 
the introduction of the poison into his economy, either 



22 PRACTICAL CLINICAL LESSONS ON 

at the point of inoculation, or through any constitutional 
disturbance or internal or external sensation of any de- 
scription whatever. 

No feature in the development of syphilis is of more 
practical importance than this period of apparent incu- 
bation. A failure to appreciate it is fraught with dis- 
comfiture to both physician and patient. Lulled into a 
false security by the healing of a lesion following an 
illicit venereal contact — even assured of freedom from 
disease by his medical adviser — many an unfaithful 
benedict returns to his marital allegiance, only to realize 
the disaster after an innocent wife has been infected with 
syphilis, and through her the disease, it may be, trans- 
mitted to a luckless embryo. 

The period of apparent incubation, according to au- 
thorities, varies in different subjects from ten to seventy 
days. The causes of this variation are not well under- 
stood. It is supposed by some to depend upon the de- 
gree of activity of the particular specimen of virus in- 
oculated ; by others upon some peculiar condition or 
idiosyncrasy of the subject. The fact, however, that in 
the great majority of cases of experimental inoculation 
of the virus, from whatever source, the results are much 
more uniform, being seldom less than eighteen nor 
more than thirty-five days, would lead to the belief that 
other influences than quality of the virus or peculiarity 
of the individual affects the term of apparent incuba- 
tion. Experiments in regard to the contagiousness of 
non-specific pus have demonstrated its erosive property 
under certain conditions. Secretions from a diseased 
uterus, and even from the Schneiderian membrane, are 
known to produce excoriation of sound mucous tissues 
and of integument, and even to set up a true ulcerative 
process. We may then easily admit the possibility of 
admixture of the simple non-irritating secretion from 
an intra-vaginal syphilitic lesion with secretion from 
a diseased uterus, capable of effecting a solution of 
continuity in sound tissue ; the time required for such 
an effect varying with the degree of irritant power 
and the condition of the part to which it is applied. 
Thus, in the folds of integument upon the penis, 



SYPHILIS AND THE GENITO-URINARY DISEASES. 23 

where heat and moisture are at the minimum, with 
even a decidedly vicious secretion, many days might 
elapse before the dry cuticle would be eroded sufficient- 
ly to afford entrance to the accompanying syphilitic 
poison ; or, on the contrary, should the secretion be 
applied to the moist delicate lining of the prepuce, the 
solution of continuity would be greatly facilitated. 
Again, in case of fracture of the skin or mucous mem- 
brane, ulcerative action might be set up coincidently 
with the vicious contact; and yet in neither case 
would the lesion be due to or indicative of the presence 
of the syphilitic virus. And this fact, that the syphilitic 
virus may be associated in the same individual with 
vicious uterine secretions, and also with the specific 
secretions of chancroid capable of effecting a solu- 
tion of continuitv in sound integument or mucous 
membrane, naturally leads to frequent errors in diag- 
nosis. There is, I repeat, absolutely nothing in the 
condition of the patient, at the point of entrance of 
the svphilitic poison, or at any other point, which 
can be considered a proof of syphilitic infection, until 
the termination of the (so-called) period of incuba- 
tion. And this time is announced by a peculiar change 
in the condition of the tissues at the point of entrance of 
the virus, and nowhere else; this change, too, occurring 
equally whether an abrasion or ulceration has been 
previously established at this point by other causes, or 
when the healing has immediately followed the intro- 
duction of the virus. An exudation or development of 
cellular and fibro-plastic material takes place in the tissue 
at the point of entrance of the contaginm; and this pro- 
cess results in an induration perceptible to the touch, and 
establishes a well-defined characteristic mark of syphili- 
tic infection. This, under the microscope, is found to 
consist of lymphoid or germinal cells apparently accu- 
mulated and proliferated in loco, as a direct result of the 
syphilitic inoculation. The excessive localized prolifer- 
ation of cell elements constitutes a marked feature in 
every stage of syphilis. Its first appearance at the site of 
entrance of the poison forms the initial lesion, or the first 
positive manifestation of the syphilitic influence. The 



24 PRACTICAL CLINICAL LESSONS ON 

course and duration of the initial lesion varies in different 
subjects, in some cases appearing as a nodule covered 
by sound cuticle or mucous membrane, varying- from a 
slight increase in thickness to a distinct cartilaginous 
nodule as large as a pea. It may remain stationary for 
a time, and then terminate in resolution — that is to say, 
undergoing fatty degeneration, become quietly ab- 
sorbed ; or it may take on a more active process, in- 
volving the destruction of the overlying tissue and an 
acute disintegration of its elements ; carrying away with 
them a certain limited amount of the original cellular 
tissue involved in its meshes, and producing an ulcer- 
like lesion, but which, however, is independent of true 
ulcerative action ; its secretion thin and serous, made 
up, not of pus, but of hastily generated cell material; 
its natural course sluggish, and but little influenced 
by local treatment ; healing at last, over the induration, 
while the induration continues dense and characteristic, 
not unfrequently throughout the entire course of the 
constitutional disease. 

Some of the points of interest in regard to the incu- 
bation and induration of syphilis, which I have briefly 
set forth, will be apparent in the cases which are now 
before you. From the first, James B., aged 23, we glean 
the history of an exposure about the 13th of August 
last, followed by a soreness of the " bridle" or frenum, 
which lasted for two or three days, from which time 
nothing especial was observed until the second week 
in September, when he noticed a " bunch" in the loose 
tissue of the frenum which became chafed about a week 
ago, and made a sore, and which grew gradually larger 
up to the present time. It is now, as you can see, about 
the size of a threepenny piece, shallow and smooth, 
presenting a fine granular surface with but little moist- 
ure. As you pinch it up between your thumb and 
finger, the induration of which I have spoken may be 
distinctly felt ; and I present this case to illustrate the 
history of its origin, and which is classical for a single 
variety, and that you may test the induration, which is 
well marked, 

In Case II., George W., a baker, aged 19, presents 



SYPHILIS AND THE GENITOURINARY DISEASES. 2$ 

three points of apparent ulceration, one upon the side 
of the frenum about the size of a split pea, and two 
a little larger, in the furrow behind the glans penis. 
George has no distinct remembrance of the time after 
exposure when these sores first appeared, but thinks 
about a week or ten days ; has had them about a fort- 
night ; has been to a physician, " who burned them with 
caustic" several times. 

The true syphilitic lesion is usually, though not al- 
ways, solitary, as in the case first presented. Here the 
existence of three points of lesion, and appearing within 
two days from exposure, militates against the idea of 
their syphilitic nature. You will also remember that 
the characteristic syphilitic lesion at the point of en- 
trance of the virus is seldom less than 15 or more days. 
There is, however, a distinct induration about the base 
of these sores, little if any less than that which you 
recognize in Case I. But when I tell you that simple 
sores and even incised wounds become indurated by 
irritant applications, and you recall the patient's state- 
ment that these have been " burned out with caustic," 
you will realize the difficulty of making a clear diagnosis 
at present. We will advise a simple water dressing, 
and if the induration is due to the application of the 
caustic it will soon disappear. 

Case III. We have here in a patient, 36 years of age, 
a mass of induration of the size of a hickorv-nut, devel- 
oped in the tissue of the inferior portion of an elongated 
prepuce. Phymosis, or closure of the preputial orifice, 
has resulted, and is almost complete. He complains, 
from this cause, of much difficulty in passing his water. 
On pressure, a gray, serous-looking fluid exudes from 
the preputial orifice ; a shallow excoriation of its inner 
surface is observed when the prepuce is strained back. 
The glands of the groin are distinctly enlarged, but pain- 
less ; a distinct papular eruption covers his chest, arms 
and back. The history of this patient develops an ex- 
posure two months ago — not for a month previous, and 
not since. Three weeks after connection he noticed a 
" hardness," about the size of a pea, inside the prepuce, 
which has been growing ever since. He has had no 



26 PRACTICAL CLINICAL LESSONS ON 

trouble from it except the pain in passing water. This 
case appears to me a clear one of syphilis. If the indu- 
ration and its history were not sufficient, we have posi- 
tive proof in the additional evidence furnished by the 
glandular swellings and the coppery papular eruption — 
the significance of which I shall have occasion to refer 
to on a future occasion. An operation is here called for, 
to remove the indurated mass on account of the phymo- 
sis which it has occasioned. I shall, therefore, proceed 
to remove the entire prepuce by the introduction of a 
director upon the superior surface of the glans, and 
back as far as the fossae ; then passing along it a curved 
bistoury, I bring it out over the fossae glandis, and, di- 
viding the intervening tissue, remove the redundant 
mass, including the induration, with a single cut on 
either side, completing the incisions at the frenum. 

You will observe that the hemorrhage here is very 
slight, no vessels of much size having been severed. 
Usually there is quite free bleeding from the vessels of 
the frenum, in such case requiring ligature. The op- 
eration will be completed by bringing the cut surfaces 
into apposition with a very fine silk thread, by the glo- 
ver's suture, which 1 invariably use in bringing the cut 
edges together after a circumcision. 



SYPHILIS AND THE GENITOURINARY DISEASES. 27 



LESSON II. 

Non-Auto-inoculability of Chancre — Exceptional Cases — Prevention of 
Constitutional Infection through Excision of the Chancre Denied — 
Rapidity of Infection through Germinal Material in Proportion to the 
Rapidity of the Cell Proliferation and Size of Corpuscles Diminishing 
in same Ratio — Syphilis Characterized by Comparatively Slow Prolif- 
eration — Infective Cells in Syphilis not necessarily Differing greatly 
in Size from Normal Germinal Cells — Differing only in Amount, Pe- 
culiar Aggregation, and Characteristic Infective Property — Gross Ap- 
pearances of ihe Excised Chancre — Microscopical Examination — 
Beisiadecki's Observations in Twenty Specimens — Confirmation of the 
Claim that the Initial Lesion is Formed by Cell Proliferation; in loco, 
and not the Result of Inflammatory Action — The Open Lesion a Legiti- 
mate Result of Interference with the Vessels of Nutrition from Me- 
chanical Pressure caused by the Cell Accumulation — Clinical Cases 
Illustrative of Characteristics of Chancroid. 

Iii briefly characterizing the initial lesion of syphilis, 
In the previous lesson, I spoke of it as non-inoadablc 
upon t lie person bearing it. This may be laid down as a 
rule where the Chancre (as this lesion is usually termed) 
has not been subjected to irritation sufficient to set up 
a purulent discharge. When pus is present, however, 
inoculation may result in an ulcerative lesion. In Case 
III., previously cited (p. 25), the lesion was apparently 
free from this complication, so that its removal will 
not be liable to inoculate the cut surfaces. 

The effect of removal of indurated chancre by exci- 
sion has been the subject of controversy, some authori- 
ties claiming that early excision of the initial induration 
may wholly prevent systemic infection. Auspitz and 
Kolliker, of Vienna, the former in 1877 an d the latter in 
1878, reported cases, in all numbering about 40, where 
such excision was believed to be effectual in preventing 
the occurrence of constitutional syphilis. It was even 
stated that in several of these cases enlargement of the 
inguinal glands was already well marked at the date of 
the operation. It is difficult to understand how such a 
claim can be seriously advanced when there is such 



28 PRACTICAL CLINICAL LESSONS ON 

positive proof that the disease has already involved the 
lymphatic system beyond the site of the initial lesion ; 
and when we consider the fact that the inguinal glands 
are involved, as a rule to which there are few excep- 
tions, by the time the induration of the initial lesion is 
distinctly recognizable, we must deny, absolutely, even 
the possibility of the cure of syphilis through excision 
of the initial lesion alone. It is now beyond question 
that the infective principle of syphilis entering at a 
given point gradually invades the system — and as far 
as we are able to trace it by gross appearances and 
microscopic examination it is confined to the lympha- 
tic vessels and glands until it enters the blood through 
the great lymph channels. Its presence, as has been 
previously stated, is signalized by local cell accumula- 
tions, producing the characteristic enlargement and in- 
duration, first at the point of inoculation, then of the 
adjacent lymphatic glands, and subsequently of every 
recognized lesion of the active stage of the disease. 
Inoculation of all or any of the juices or secretions of 
these lesions upon healthy persons will surely communi- 
cate syphilis to such persons. Such secretions, under the 
microscope, are found laden with cell material: germ- 
inal matter analogous to that which has been demon- 
strated by Beale, Chauveau, Burdon-Sanderson and 
others to contain the infective principle of variola, re- 
lapsing fever, the cattle-plague,* etc., previously re- 
ferred to. The rapidity with which the infective ger- 
minal material is proliferated, would appear by the 
statements of the authorities just mentioned, to be in 
proportion to the malignity of the disease, and the size of 
the infective cells or corpuscles to diminish in the same 
proportion. It is not then remarkable that in a disease 
like syphilis, when its development is so gradual that 
months elapse before its climax is reached, the cell 
element should vary but little from the normal condi- 
tions. This would appear to be not improbable, for the 
closest microscopic investigations have failed to dis- 

* Disease Germs, their Nature and Origin. Lionel Beale. London, 
1872. Page 143, etc. 



SYPHILIS AND THE GENITOURINARY DISEASES. 2Q 

tinguish the diseased from the healthy cell material, 
and it is only by its abnormal amount and peculiar ag- 
gregation, together with its infective property, that it 
can be differentiated from the most healthy germinal 
matter. I will now call your attention to the gross 
physical characteristics of the initial lesion (^Case III.) 
just removed by excision. 

It has exactly the appearance and feel of a mass of 
cartilage, and the sensation transmitted through the 
fingers as the knife is drawn through it is the same as 
if cartilaginous material were divided. There is no 
appearance of vascularity. The preputial tissue in 
which it is imbedded, and in which it is freely mova- 
ble, is apparently free from disease. The microscopi- 
cal examinations of such indurations show that they are 
made up of cell accumulations which involve even the 
walls of the blood-vessels, and bear out very strongly 
the claim that they are not the product of an inflamma- 
tory process, but of a local cell proliferation at this 
point. Alfred von Beisiadecki, of Krakow, has given 
us the results of a very exhaustive microscopical exami- 
nation of twenty specimens of this variety of indurated 
tissue.* He says : " The induration consists in a cell in- 
filtration of the papillae of the corium and subcutane- 
ous connective tissue. The infiltrated cells are similar 
to those of dermatitis. They are round, have one or 
two nuclei, have a finely granular protoplasm, and 
separate the connective tissue equally. These fibres 
retain the normal size, are not infiltrated as in derma- 
titis ; they are apparently denser and more resistant to 
chemical reagents. But the arrangement of the cells 
differs from that in dermatitis. In those places where 
a rich cell proliferation has taken place, and in their 
vicinity still more, we find that the neighboring tis- 
sues of the vessels, as well as of their walls, are abund- 
antly infiltrated with cells. The walls of the capillarv 
vessels of the papillae are thickened, have a shining and 
rigid appearance, and enclose numerous nuclei, which pro- 
ject even into the lumen of the vessels. The adventitia of 
\ . 

* Archives of the Academy of Sciences of Vienna, 1S67. 



30 PRACTICAL CLINICAL LESSONS ON 

the arteries and veins is three times its normal thick- 
ness, in consequejice of the presence of numerous round, 
spindle-shaped and branched cells. The calibre of the 
cells is diminished, but the vessels are permeable. If 
the induration still increases, we find in its vicinity an 
abundant proliferation in the adventitia of the vessels, 
and subsequently the adjoining connective-tissue cells 
enlarge and proliferate and anastomose with those situ- 
ated in the adventitia by means of their processes." 

" The induration is explained, however," he further 
remarks, " neither by the number of cells nor by their 
peculiar properties, but by the fact that while in derma- 
titis we have a proliferation of cells, and also a serous 
exudation which infiltrates the tissues and fibres, in the 
induration of syphilis we have a dry anaemic tissue, 
resistant connective-tissue fibres, considerably thick- 
ened walls of vessels. The dryness of the induration, 
which produces the hardness and also the anaemia, is 
caused by the proliferation in the walls of the vessels, 
which makes it difficult for the serum to leave the 
vessels, and also diminishes their calibre. And this," he 
says, " explains why the syphilitic induration breaks 
down into a molecular mass, and why resorption takes 
place so slowly." 

Now, in contrast with the indurated tissue associated 
with and characteristic of the initial lesion of syphilis, 
I wish to direct your attention to another patient, Case 
IV., who presents a sharply defined ulcer occupying 
the central portion of the fossae glandis, encroaching 
upon the glans and also upon the reflexion of the pre- 
puce. It is fully as large as a dime, and, as you see, 
something like a figure 8 in form. The history given 
by the patient is that a little over a month ago he had 
a suspicious connection, and within a few days — he is 
not quite certain, but not more than five — he observed 
"two small festers" (pustules), which soon discharged 
and grew until they formed a single sore. He has 
made repeated applications of " blue-stone" (cupri 
sulph.), and thought he was getting better, when, a few 
days since, his right groin began to be swollen and 
painful, and he has come to us for relief. 



SYPHILIS AND THE GENITOURINARY DISEASES. 3 1 

On pressing this ulcer between the thumb and finger 
it is found to be quite free from hardness, although the 
caustic treatment to which it has been subjected would 
be likely to develop more or less induration. The 
edges are abrupt, the floor is irregular and covered 
with a yellowish debris composed of pus and dis- 
organizing tissue ; the surrounding border is red and 
somewhat swollen, and also quite tender, as you can 
observe by the shrinking from our very careful manipu- 
lation. We have here, then, judging from the history 
and appearance and condition, a characteristic example 
of the contagious venereal ulcer, previously referred to 
as second among the contagious venereal disorders, and 
called chancroid. If there was still a doubt as to its 
nature, it is dispelled by the inflamed and swollen con- 
dition of the right groin. We recognize by gentle 
palpation a small abscess of one of the inguinal glands, 
a not uncommon result of the chancroidal action. Pus 
from the chancroid, gaining access by ulceration to the 
interior of a lymphatic vessel, passes at once into the 
gland in connection with it, and through its contagious 
and destructive property goes rapidly on to the pro- 
duction of a virulent abscess, the pus of which is con- 
tagious and destructive equally with that of the 
chancroid. The chief characteristic of the chancroid, 
you will observe, is its destructiveness. It begins as a 
pustule, resulting from necrosis of tissue, set up by con- 
tact of a molecule of chancroidal pus. Throughout its 
existence its secretion furnishes pus which, brought 
into contact with healthy tissue, sets up a destructive 
action of greater or less activity. It is simply, only and 
always destructive, and without the destructive prop- 
erty it cannot be chancroid. It is the antithesis of the 
initial lesion of syphilis, which in its inception is a 
process of growth instead of dissolution, and in which 
loss of tissue occurs not by any virulent agent, but by 
such an accumulation of new material as to embarrass 
and finally to arrest the processes of nutrition, and in this 
way result, in instances like that of Case III., in an open 
lesion. The microscopic examinations of Beisiadecki, 
which have been amply verified by Auspitz, Verson, 
etc., prove this almost beyond question. 



32 PRACTICAL CLINICAL LESSONS ON 



LESSON III. 

The Cell Accumulation of the Initial Lesion of Syphilis in Harmony 
with what is proved to occur in every Lesion during the Acute Stages 
of the Disease — Cell Proliferation, in loco, always Sufficient to Explain 
Satisfactorily the Cause and Condition of the Lesion — Gradual Prog- 
ress of the Infected Cells through the Lymphatic System until the 
General Blood Current is Reached — Practical Denial of the Views of 
Instant Infection, with Corroborative Proofs — Incubation of Syphilis — 
Different Modes of Transference of Syphilis— Most frequent Locations 
of the Initial Lesion — Communication by Direct Contact through the 
Act of Kissing, through Surgical and Gynecological Operations, etc. — 
Communication of Syphilis through Mediate Contagion or through 
any Material which has been in Contact with the Secretion of any 
Lesion of Active Syphilis — Directions for the Prevention of such Acci- 
dents — Eight Cases Illustrative of this Mode of Acquiring Syphilis by 
Medical Men. 

The significance of the induration in the initial lesion 
of syphilis as thus explained is most important, and will 
be found to be in harmony with and typical of each and 
every manifestation or lesion throughout the active or 
acute stages of the disease. The cell accumulation 
which has been demonstrated to constitute this indura- 
tion has been found to occur in the lymphatic vessels in 
communication with it, not infrequently recognized, 
like knotted cords under the integument, running to the 
lymphatic glands into which they empty, which in turn 
become depots for the proliferative process, and enlarge 
in the manner shown in Case III. (see page 25), and are 
claimed and proven to be characteristic of the presence 
and advance of the syphilitic disease. The induration 
associated with the initial lesion of syphilis, then, is the 
result of a gradual invasion of the tissues, commencing 
at the point of inoculation or contact of the syphilitic 
principle, or so-called virus, with an open lesion of 
the integument, or mucous membrane. It is a most 
significant and important fact that, since the micro- 
scope has been applied to the investigation of syphi- 
litic disease, no lesion or manifestation of it has failed 
to present evidences of cell proliferation, in loco, suf- 



SYPHILIS AND THE GENITO-URINARY DISEASES. 33 

ficient in amount to explain, in a satisfactory way, the 
cause of the lesion. It has also in the same manner 
been demonstrated that this localized cell proliferation 
and accumulation occurs in a methodical way, progress- 
ing steadily from its point of beginning, or first contact 
with the syphilitic virus or principle, gradually invading 
the lymphatic vessels and glands, until it reaches the 
great lymph reservoir, the receptaculum chylt, through 
which it reaches the general blood-current by the sub- 
clavian veins.* All this, it will at once be seen, is in 
direct opposition to the views formerly, and to a great 
extent still, held, viz., that the virus of syphilis enters 
the blood at the instant of inoculation, and that thus 
" the entire organism is affected at once."f Such a 
claim is purely theoretical and unsupported by a 
single scientific proof, while the evidences of a gradual 
infection, through the lymphatic system, are not alone 
met in microscopical examinations by distinguished 
scientists, but are confirmed by the clinical observa-- 
tions of every careful observer ; each succeeding 
lesion or manifestation from the initiation to the termi- 
nation of the disease adding corroborative proofs, not 
only by its physical characteristics, but by the date of 
its appearance. 

THE SO-CALLED INCUBATION OF SYPHILIS. 

This is a term usually applied to the period which 
elapses from the date of inoculation to the appearance 
of the characteristic initial lesion, and may vary in dif- 
ferent cases, according to different authorities, from 
one to seventy days, the usual time being from ten to 
twenty-five days. Strictly speaking, syphilis has no 
period of true incubation, inasmuch as the process of 
cell proliferation is undoubtedly established at the mo- 
ment the virus (disease cell or germ) comes in contact 
with the germinal or white blood cell of the human 
organism. 

* See Otis on the Physiology and Pathology of Syphilis. G. P. Put- 
nam's Sons. New York, 1881. 

f Billroth, Surgical Pathology. Am. ed., p. 386. 



34 PRACTICAL CLINICAL LESSONS ON 

The immediate effect of such contact seems to be a 
rapid increase in the process of proliferation of such of 
the normal white blood cells as have become contami- 
mated or degraded by the influence of the disease germs 
(virus) of syphilis. Through accumulation of this de- 
graded product, the tissue (including the vessels of nu- 
trition) at the point of initiation of this process, becomes 
densely packed, forming a neoplasm of greater or less 
extent. The process of degradation or infection is con- 
fined to the immediate locality of the inoculation, until 
the degraded cells have gained access to the interior of 
a lymphatic vessel. Through this channel the diseased 
cells are carried to the nearest lymphatic gland (the 
gland of connection, as it may be termed), and here are 
arrested, by the peculiar conformation of the gland 
structure, for a longer or shorter period (usually about 
six weeks), during which time there is no further evi- 
dence of constitutional infection. 

This period of apparent rest is usually termed the 
second incubation of syphilis. 

Note. — It is probable that the interval between the date of inoculation 
and appreciable gland enlargement is dependent upon the facility or dif- 
ficulty with which the diseased cells gain access to the lymphatic vessel 
connecting the point of inoculation with the adjacent gland. Hence, at 
points where the distribution of lymphatic vessels is most liberal and 
most superficial we should expect to find the shortest interval between 
inoculation and gland implication. This view is supported by the clini- 
cal fact that, in cases when the shortest interval occurs, the initial lesion 
(in the male) is located at the frenum, or the anterior-inferior surface of 
the glans penis. From this point, chiefly, the superficial lymphatic ves- 
sels radiate, and are (according to Balaieff) " most superficial, rising, in 
this especial locality, until they lie just underneath the epithelium" (see 
Otis on the Physiology, Pathology, and Treatment of Syphilis (Putnam 
Sons, 1880), pages 12 and 13, where it is shown that, by direct introduc- 
tion of the syphilitic element into the interior of a lymphatic vessel, dis- 
eased action, in the gland of connection, is inaugurated at once).. 



MODES OF TRANSFERENCE OF SYPHILIS FROM THE 
DISEASED TO THE HEALTHY. 

The modes of transference of syphilis from the dis- 
eased to the healthy are three : 
(1) By Direct Contact of the diseased surface with 



SYPHILIS AND THE GENITOURINARY DISEASES. 35 

an abrasion, or other breach of tissue, on a healthy per- 
son. 

(2) By Mediate Contagion. 

(3) By Hereditary Transmission. 
Communication of syphilis by Direct Contact (as 

under the circumstances peculiar to the venereal act) is 
the most frequent mode of the acquirement of syphilis. 
In the female, initial lesions from this source are most 
common in the vicinity of the ostium vagina? ; especially 
so in the folds of mucous membrane about the fourchette; 
between the greater and lesser labia?; under the sheath 
of the clitoris ; upon, and even within, the meatus urina- 
rius. They are also found to occur, not unfrequently, 
about the anus; they are rarely found on the os uteri, 
and still more rarely on the vaginal ruga?. 

In the male, the most frequent sites are upon the glans 
penis and prepuce, occurring- with especial frequency in 
the sulci by the side of the frcnum, at the meatus urina- 
rius, and in the fossa? glandis, and occasionally on the 
integument of the penis. 

In both sexes the initial lesion is sometimes found upon 
either lip, in the angles of the mouth, or even within it, 
and also near, or within, the anus; all as a result of di- 
rect contagion. Communication of syphilis by direct 
contact, through the act of kissing, is an accident of oc- 
casional occurrence. There is also a danger that it may 
be transferred, through the act of nursing, from syphi- 
litic infants to healthy wet nurses, or from syphilitic 
nurses to healthy infants. Relations between nurses 
and children should never be entered into without a 
careful consideration of this fact. In these cases, the 
inoculating secretion may be furnished, either by an 
Initial Lesion, or by one of the common manifestations of 
active syphilis, known as the Mucous Patch. 

Initial lesions are also found in various other localities, 
as solutions of continuity, at any point, may become the 
accidental recipients of the syphilitic contagium. Usually, 
they are rare in proportion to their distance from the 
genitalia. Surgeons, accoucheurs, and gynecologists 
are especially exposed to the peril of an innocent inocu- 
lation of syphilis by direct contact. Within the circle 



36 PRACTICAL CLINICAL LESSONS ON 

of my city acquaintance, at the present time, are three 
medical gentlemen who acquired syphilis through an 
initial lesion on the right forefinger. In another case, 
a surgeon, also an acquaintance, received the syphilitic 
inoculation in the end of his right forefinger, through 
accidental puncture, by a spicula of bone, while ampu- 
tating the leg of a syphilitic subject. 

Inoculation of Syphilis through Mediate Con- 
tagion. — Cells diseased by the syphilitic influence (or 
what is usually termed the syphilitic virus) may cling to* 
substances with which they are brought into contact. 
All degraded animal cells, or disease germs, have the 
power of maintaining their vitality for some time after 
removal from the organism in which they have been de- 
veloped. (Beale.) Any material, therefore, which has 
been in contact with the secretions of syphilitic lesions, 
or the blood of a syphilitic, during the active stage of 
syphilis, may prove the medium of communication of 
syphilis to a healthy person, provided, only, that the 
substance so contaminated is brought into contact with 
a lesion, however slight, of the skin or mucous mem- 
brane. 

The most common source of the contagium, in cases 
of Mediate Contagion, is the Mucous Patch, a consti- 
tutional sy^philitic lesion, frequent upon the mucous 
membrane of the lips, mouth, and faucial region, in per- 
sons passing through the active stages of syphilis. The 
saliva is thus impregnated with the syphilitic disease 
germs, and, through it, a variety of domestic utensils 
have been the known medium of syphilitic inoculation, 
by contact with abrasions upon the lips of healthy per- 
sons, without regard to age or sex. In the same way, 
pipes passed from syphilitic mouths, cigars from syphi- 
litic cigar-makers, canes, pencils, and even sticks of 
candy, contaminated by syphilitic saliva, have effected 
a syphilitic inoculation. Within the last eighteen 
months I have met with four cases where there was un- 
doubted proof of the acquirement of syphilis through 
mediate contagion. One, of a young lady, with the 
initial lesion on the lower lip, acquired from her lover's 
kiss. The second, a physician, with the initial lesion 






SYPHILIS AND THE GENITOURINARY DISEASES. 3? 

just within the angle (on the right side) of the mouth, 
from a syphilitic friend's pipe. The third, in the same 
locality /appearing, characteristically, about three weeks 
after a morning spent in a dentist's chair. The fourth, 
a worthy merchant, with his initial lesion (well marked) 
on his lower lip, with mucous patches in his mouth, and 
an accompanying syphilitic iritis. In this latter case 
the only clue to the mode of acquirement of syphilis 
was the habit of passing among numerous clerks and 
occasionally transferring a lead pencil from their desks 
to his mouth. 

Well-marked constitutional syphilis, with complete 
absence of any genital lesion, was present in each case 
cited. 

The foregoing typical cases, illustrative of the modes 
through which syphilis may be contracted by Mediate 
Contagion (with the exception of the last), were seen in 
consultation with physicians from neighboring States. 
Such accidents, however, are of more likely occurrence 
in great cities, where moral restraint is least stringent 
and opportunity for acquiring venereal diseases most 
favorable. It becomes necessary, therefore, in connec- 
tion with cases of obscure disease, simulating syphilis, 
to make a searching scrutiny of all incidents, conditions, 
and exposures which may, in the light of possible ac- 
cidents, point to opportunity of syphilitic infection 
through mediate contagion. The third case cited is of 
especial value, as conveying a lesson on the necessity of 
scrupulous care of instruments used in operations about 
the mouth. 

So simple a procedure as the depression of a patient's 
tongue with a spatula, in examinations of the mouth and 
throat, may easily become the means of canwing the 
syphilitic disease germ to an abraded surface in a healthy 
person. 

In all cases, therefore, where the same instruments 
are in use for different persons, after thorough cleans- 
ing, their passage tJirongh the flame of an alcohol lamp 
should be systematically practised after every opera- 
tion. The same procedure is equally indicated in re- 
gard to instruments used upon other mucous membranes, 



38 PRACTICAL CLINICAL LESSONS ON 

as those lining the urethra, the bladder, the rectum, the 
eye. It is also essential in all instruments used in cut- 
ting operations at any point. Not the least important 
among the modes of conveying syphilis by mediate con- 
tagion is that by vaccination. Numerous well-authenti- 
cated cases of this disaster may be found recorded in 
any modern systematic work on syphilis. Inoculation 
of syphilis by vaccination may be effected either by an 
impure virus or an unclean knife. Use of the bovine 
virus, by means of a clean instrument, relieves this benefi- 
cent operation from the stigma of being considered a 
possible means of communicating syphilis. 

Extract from the Independent Practitioner. 

EIGHT CASES OF SYPHILIS OF THE FINGER IN MEDICAL 
MEN. REPORTED BY FESSENDEN N. OTIS, M.D. 

Case I. W. N., M.D., set. 26, was in good general health up to three 
weeks ago. In the latter part of September, 1881, he noticed a small, 
red papule on the superior surface of the forefinger, at the middle of the 
second phalanx. He had been for over a month on the venereal service 
of Charity Hospital. He had never noticed any previous abrasion at 
the point of appearance of the papule. He is not aware of having had 
any special exposure of this finger. He had been in the habit twice a 
week of making vaginal examinations of venereal patients. The papule 
was painless, had a pale red color and a slight boggy feel, but was without 
distinct induration. Thinking it might contain a splinter, an incision 
was made into it, but no splinter was found; no pus, only blood, escaped. 
This cut remained open and assumed the form of a small ulcer with 
sharply cut edges, -^ of an inch in diameter and T \r of an inch in 
depth, circular, with smooth, shiny, red floor. This exuded a secre- 
tion which accumulated, dried, and formed a scab which dropped off at 
the end of twenty-four hours, with an escape of 3 or 4 drops of sero- 
purulent fluid. It would exude, dry, and scab over again. I examined 
it about the 10th of November, when exudation first commenced, and 
detected in connection with it an enlarged and somewhat tender gland 
in the axilla. Several days after I found an enlarged epitrochlear gland 
in the right arm. A deep red areola with a scaly border now surrounded 
the lesion. Patient's health was good up to three weeks ago (or six 
weeks after the discovery of the papule), when without apparent cause 
he began to suffer with headache and general malaise. Insomnia well 
marked; appetite pretty fair. He, however, kept about his work at the 
hospital; he had some febrile excitement; temperature about 100 in the 
evening. These symptoms all disappeared in about ten days, and he re- 
turned to his general health, and was feeling perfectly well, when on 
December 18, looking, as had for some time been his habit on retiring, 
he discovered on his body a distinct eruption which he described as papu- 
lar in character. 

Examination at the present time (about eleven weeks from the discov- 



SYPHILIS AND THE GENITO-URINARY DISEASES. 39 

ery of the original lesion) shows a discrete eruption of papules both fine 
and coarse, scattered over the body, most prominent on the chest and 
arms, and pale red in color; also distinctly indurated glands in cervical, 
epitrochlear, and inguinal regions, characteristically enlarged, and one 
also in right axilla enlarged and tender. The throat is congested, a 
single scab is found in the hair. The patient, who had been desirous of 
waiting until the diagnosis of syphilis was absolutely certain, was now 
put upon a systematic treatment for that disease. 

Case II. 1878, S. S. B. ; presented with a papule of the middle finger 
of right hand, about the size of a silver three-cent piece, just over the 
second joint, elevated and non-suppurating. It appeared as a red spot 
about two weeks previous, and has gradually become elevated, and with 
no distinct induration. About six days ago a dry scale appeared in the 
centre and a molecular necrosis started from that joint. He has poulticed 
it for the last week. There is no local tenderness but some pain in the 
arm stretching up from the lesion as far as the elbow. A single en- 
larged gland is found in the corresponding axilla about the size of a fil- 
bert. 

The patient was advised that the lesion was probably syphilitic, and 
instructed to wait for signs at other points. In this case there was no 
positive induration about the lesion, only a boggy feel. The patient has 
no idea of any date of exposure. He attended a confinement on April 6, 
but had no suspicion of syphilis in the case. 

I lost sight of this patient until July, 1881, when I was informed by 
Dr. E. F. Ward, of New York, that he subsequently had roseola and a 
papular eruption developed, and that he was at this time suffering from 
hemiplegia, which had come on suddenly. 

Case III. In latter part of December, 1871, the patient, a physician, 
noticed a red spot upon the dorsal surface of the right index finger, near 
the base of the second phalanx. The spot when noticed was about an 
inch in diameter, and continued slowly to increase in circumference and 
to become raised, until within three weeks it reached nearly the size of a 
three-cent piece and looked precisely like a vaccine vesicle without a 
central depression. It soon became incrusted, but by the application of 
poultices the crust was removed, leaving a well-rounded ulcer about one- 
third of an inch in diameter, excavated, clean, without discharge, the 
edges raised and all of a deep red color and sluggish in appearance, 
neither inclining to heal itself nor to yield to treatment. The base was 
boggy and no induration whatever could be discovered, although searched 
for by a distinguished surgeon in this city, and by him the lesion was 
confidently pronounced to be at most a si?nple chancre. Another surgeon 
familiar with syphilis was equally confident of its simple character. A 
third who saw it while a small papule regarded it with suspicion, and 
advised the patient to consult some surgeon who gave especial attention 
to such cases. The patient then came to me. My opinion was strongly 
in favor of a syphilitic origin for the lesion, but the patient desired to 
wait for further proof before commencing constitutional treatment. 
The ulcer showed no sign of improvement. The extended finger was 
bandaged to a splint, rendering the point immovable, and allowed to re- 
main so two weeks, but without improvement. I then advised the appli- 
cation of iodoform powder. Within forty-eight hours a decidedly favor- 
able change had taken place, and within ten days the ulcer was perfectly 
healed. Once or twice afterward the skin was accidentally broken, but 



40 PRACTICAL CLINICAL LESSONS ON 

on reapplying the iodoform it healed kindly. From the first appearance 
of the spot till the healing of the ulcer no pain or discomfort was felt. 
After some four months — that is to say, in the following April — the doctor 
called to inquire about an eruption which had made its appearance a 
week or two previously upon his breast and arm chiefly, sparsely on his 
face and head, which was quite bald. The eruption was of a dull red 
color, slightly elevated, and several papules were encircled by a line of 
exfoliating epidermis. They were free from itching, and were discovered 
by the accident of their appearance on the face and scalp, as they caused 
no sensation and were not preceded by any fever, headache, or other con- 
stitutional disturbance. Examination showed distinct gland enlarge- 
ments in the cervical, inguinal, and epitrochlear regions. He was then 
for the first time put on a regular mercurial course, viz., one pill of 
mass. Hydrarg., 2 gr. combined with 1 gr. of the exsiccated sulphate of 
iron, three times a day. At about this time this patient's wife began to 
complain of a profuse vaginal discharge, having been previously in good 
health, and free from any leucorrhoeal trouble. About three months 
subsequent to this, a characteristic papular eruption appeared on her 
face and body, general gland enlargements distinct and prominent in 
groin, neck, and epitrochlear regions. She too was then put on a system- 
atic mercurial course similar to that of her husband. Both were kept 
under treatment for about a year and a half, when no signs of syphilitic 
trouble having appeared for several months, it was discontinued. To- 
day, Feb. 21, 1882, the doctor reporting by my request, states that now 
nearly ten years from the disappearance of the disease, and the cessation 
of all treatment, both he and his wife have been and are now free from 
any evidence of syphilis. 

Two other cases of the occurrence of syphilis in physicians where the 
initial lesion was situated on the right forefinger have been reported to 
me during the present winter, and in addition to these I am cognizant 
of three other cases in New York City, two gynecologists and one dis- 
tinguished surgeon, who have had syphilis through an initial lesion of 
the finger. 

The first point of interest in considering the foregoing cases is the dan- 
ger to which any physician who treats diseases of females or attends fe- 
males during the parturient condition is more or less exposed, and the 
necessity of using extraordinary precautions in examining or attending 
every case to which a suspicion of syphilis could possibly attach, and habit- 
ually to protect by previous application of elastic collodion any cracks or 
abrasions about the nails or joints of the fingers, especially of the right 
forefinger, and to use a lotion of carbolic acid (1 to 100) or of the liquor 
potassa permanganatis, 1 part to 40 of water, as a habit after all digital 
examinations of the female genital apparatus. 

It may be safely asserted that a pre-existent abrasion or fracture of the 
skin or mucous membrane is absolutely essential to the acquirement of 
syphilis; and that in any case when syphilis has been acquired without 
the recognition of a local initial lesion, it has been present, but over- 
looked. Destruction of tissue is not essential to the perfect initial lesion 
of syphilis. 

Healing of an abrasion may take place after an inoculation, just as 
promptly and as perfectly as if no inoculation had taken place, and the 
point of induration following may be so small and insensitive that it 
would easily escape observation. 



SYPHILIS AND THE GENITOURINARY DISEASES. 41 

In case of the wife of physician (Case III.), the initial lesion was not 
discovered. Her eruption was only preceded by a profuse vaginal dis- 
charge. There was never any recognized open lesion on the penis of 
her husband. It might be said of her that the inoculation had taken 
place through the influence of the semen. Mireir, of Marseilles, has made 
repeated experiments of inoculating the semen of a person in the active 
stage of syphilis, upon healthy persons, but without effect. It is more 
probable — in fact, almost a certainty — that the disease in this case was 
acquired from a syphilitic papule, of which there were at one time several 
on the penis. Abrasion occurring during coition coming in contact with 
an abrasion of the os or vaginal mucous membrane, might there establish 
the initial lesion, resulting in the vaginal discharge, which preceded the 
syphilitic eruption, which was the first recognized evidence of syphilis in 
the doctor's wife. 

The second point of interest is in the uniform and characteristic physi- 
cal appearances, presented in the initial lesion of syphilis of the finger, 
coming on always as a papule, coming soon to be of a deep red color, 
and presenting a superficial abrasion, becoming circular and deeper by a 
slow molecular necrosis; not by ulceration with formation of pus. The 
secretion thin and serous, and drying into a scab which is soon dis- 
placed by the fluid accumulating underneath. 

The entire absence of induration; in its place a slight, fiat, juicy-looking, 
boggy swelling or elevation about like a small peppermint in size and 
thickness — early appearance of an enlarged and somewhat tender gland 
in the axilla of the corresponding side. 

I would like to call attention to an interesting fact in regard to the 
efficacy of remedial measures, viz., that in five of the above-mentioned 
cases a careful systematic mercurial treatment was pursued during a 
period varying from one and a half to two and a half years. Eight 
healthy children have been born, and both they and the parents have 
continued free from any evidence of syphilis up to this date. 



42 PRACTICAL CLINICAL LESSONS ON 



LESSON IV. 

Syphilis by Hereditary Transmission — Differences of Opinion in Regard 
to the Transmission of Syphilis through the Spermatazoids — Evidence 
Furnished by the Cell Theory of Syphilis showing the Improbability 
of Infection in this Manner — The Onus of Hereditary Transmission 
Thrown Upon the Mother — The Previous Acquirement of Syphilis by 
the Mother Necessary to the Infection of the Foetus or an Embryo — 
Syphilis Transmitted only during the Active Period of the Disease; 
from One to Three Years — Reasons for this Statement — Cases Re- 
ported Claiming a Longer Period not well Substantiated — Without a 
Contagium there is no Syphilis — Errors Due to Acceptance of Imper- 
fect Evidence — Illustrative Case. 



SYPHILIS BY HEREDITARY TRANSMISSION. 

Heretofore, in considering the modes of transmission 
of syphilis, we have accepted the probable fact that this 
disease is communicated by contact of a diseased with 
a healthy human germinal cell. We have now to con- 
sider how diseased cells in the adult, male or female, 
suffering with syphilis, may be brought in contact with 
those of the embryo, or of the fcetal organism. It is 
claimed that the foetus, through the natural processes 
of growth and development, may be built up from a 
syphilitic seminal animalculae (spermatozoids) furnished 
by the male, in conjunction with an ovum furnished by 
a healthy, or even by a syphilitic, female, and may thus 
come to comparative maturity. Much clinical material 
has been adduced to prove this. On the other hand it 
is claimed, with equal proof of a similar character, that 
this is never the case, but that the syphilitic influence is 
always furnished by the female; presumedly communi- 
cated to the embryo or foetus through contact with the 
nutritive elements furnished by a mother in whose or- 
ganism the degraded cells or disease germs of syphilis 
are present. 

Like most important questions in which syphilis is in- 
volved, a solution of the foregoing, based on clinical 
evidence alone, is most difficult. The best proof of this 



SYPHILIS AND THE GENITO-URINARY DISEASES. 43 

statement is, that, on either side of all such questions, 
the most experienced and competent observers are 
ranged in nearly equal force. To constitute Hereditary 
syphilis either the embryo or the foetus must be infected. 
All infection during- or subsequent to birth must be 
classed with one or other of the modes of transmission 
of syphilis previously considered. 

If we accept the syphilitic influence to be, as pre- 
viously claimed, a degraded formative cell, we may also 
accept, as a legitimate sequence, that, through this deg- 
radation, there is a loss of formative power — an inabil- 
ity to develop into any useful tissue. 

The contagion of syphilis, as claimed, is always ef- 
fected by contact of a degraded with a healthy germinal 
cell. In a strict sense, therefore, it is always localized. 
Cells thus degraded are practically emasculated, their 
capacity for usefulness is lost. Of necessity, then, 
growth of living tissue occurring, it must take place 
through the normal cell elements, that is, through those 
which have escaped this degradation. It is thus plain 
that only a portion of the germinal material of a living 
organism can be affected by syphilis. Sufficient germi- 
nal material to carry on the processes of life and growth 
must escape, or growth would be at once arrested and 
life would cease. The possibility of involving in the 
syphilitic dyscrasia so infinitesimal a fraction of a sper- 
matic organism as would still enable it, in conjunction 
with the ovum, to play an efficient part in the growth 
and development of the human embryo, is scarcely con- 
ceivable. Especially difficult shall we find it to accept 
such a view when we consider that, once in connection 
with the ovum the syphilitic influence would be rapidly 
imparted to the germinal elements furnished by it. We 
may, then, consistently, throw the great improbability 
of continued growth (or indeed of any growth), under 
such an unfavorable influence, into the scale with the 
clinical claims of those who deny the possibility of the 
embryo or foetus being infected with s}~philis by the 
spermatozoids. With this view of the subject, the onus 
of hereditary transmission of syphilis is necessarily 
thrown upon the Mother, under all, even under appar- 



44 PRACTICAL CLINICAL LESSONS ON 

ently contradictory clinical circumstances. Hence, when 
an embryo or foetus is the subject of syphilitic infection, 
we may conclude that it is the result of contact of its 
normal formative or germinal cells, with cells degraded 
through the syphilitic influence, furnished by the nutri- 
tive fluids of the mother ; either directly through the 
circulation, or through degraded cells from her organ- 
ism, gaining access to that of the embryo or foetus by 
their amoeboid power. 

Hence, to make the syphilitic infection of an embryo 
or a foetus possible, the organism of the mother must 
first be infected with syphilis. The previous acquire- 
ment of syphilis by the mother from the father, or through 
the secretion of a syphilitic lesion, or from the blood of 
one suffering from active syphilis (by direct or mediate 
contagion), is necessary to the syphilitic infection of a 
foetus or an embryo. 

It is only during the active stages of syphilis (primary 
and secondary periods) that the contagious element of 
the different lesions of syphilis and of the blood is pres- 
ent. Therefore hereditary transmission of this disease 
is only possible during this time {usually from one to 
three years). The sequelas of syphilis (tertiary and qua- 
ternary periods) contain no discovered elements of con 
tagion. The most careful microscopical examinations 
have failed to demonstrate in the products of Tertiary 
Syphilis (various forms of gicmmata, including eruptions) 
anything besides the debris of normal germinal ele- 
ments. Repeated inoculations of these products have 
failed to disclose any contagious principle. Without 
contagium there is no syphilis. Hence we may reason- 
ably conclude that hereditary syphilis is only acquired 
during the active periods of the disease, and that in 
order to effect syphilitic contamination of the embryo 
or foetus the female organism must first be infected. 

With this view of the maternal influence in syphilitic 
infection of the foetus or embryo, cases reported, claim- 
ing such infection to have occurred through the sole 
agency of the father suffering with syphilis (the mother, 
up to this time, free from the disease), must be classed 
either among those instances where the characteristic 



SYPHILIS AND THE GENITO-URINARY DISEASES. 45 

features of the disease are absent, or where they are so 
imperfectly developed as to have escaped detection. 

The difficulty of instituting a thorough examination, 
under circumstances where it is necessary to avoid sus- 
picion of its object, the want of tact, care, and experi- 
ence in detecting obscure evidences of this disease, have, 
without doubt, too often led to the acceptance of syphi- 
lis acquired through the paternal influence, where, 
under other conditions and in other hands, infection of 
the mother would have been recognized. 

The following case will serve to indicate some of the 
various ways in which syphilis may be overlooked, and 
further, to show important variations in time and man- 
ner of development of syphilis from a similar source. 
Some three months since, Dr. W., a naval surgeon, con- 
sulted me in regard to a small nodule on the frenum 
preputialis. An abrasion was discovered, after a sus- 
picious exposure, some four weeks previous. This 
healed at once, as if simple, and nothing further was 
noticed, until the nodule, about the size of a kernel of 
pearl-barley, was observed. Its surface was abraded, 
probably during a recent connection. Its scanty secre- 
tion was found under the microscope to consist chiefly 
of laminated epithelial scales. On account of the obe- 
sity of the patient, a satisfactory examination of the 
inguinal glands was impracticable. No enlargement 
could be felt. I advised excision of the neoplasm. This 
was done at once, and healing by first intention was 
complete in forty-eight hours. 

A few days ago (December 15th) the doctor called to 
say that the operation had evidently been efficacious in 
saving him from a general syphilitic infection ; that he 
had positive proof of having, himself, communicated 
syphilis to a young lady the night previous to the ex- 
cision. In her case an initial lesion followed, in due 
time after the connection, accompanied by inguinal 
gland enlargement and succeeded by general gland 
hyperplasia. She now had, in addition, a characteristic 
papular syphilide, and yet he claimed to be absolutely 
free from the least evidence of syphilis. 

A cursor}- examination appeared to confirm the doc- 



46 PRACTICAL CLINICAL LESSONS ON 

tor's statement. This, however, appeared so improb- 
able, that I at once instituted a more thorough exami- 
nation, which resulted in the discovery, under a deep 
layer of adipose, of small but characteristic gland en- 
largements in connection with the initial lesion. The 
cicatrix on its former site was slightly indurated. 
Glands at a distance — epitrochlean and post-cervical 
regions — perceptibly enlarged. Slight but positive 
congestion of the fauces, and a narrow but characteris- 
tic mucous patcJi hidden behind the anterior pillar on 
either side. These proofs of syphilitic infection had es- 
caped the anxious search and skill of the patient, also 
of a professional associate, who was a competent and 
experienced general surgeon. 

Through evidence furnished by clinical cases, it has 
been claimed that syphilis once acquired is never fully 
eliminated from the system, but that it exists as a pos- 
sible infecting agent, after the stages which furnish 
known contagious elements are past. During more 
than twenty years of observation and especial interest 
in regard to this point I had been unable to find a sin- 
gle undoubted example, where a person in the known 
Tertiary period of syphilis (and so demonstrated by the 
absence of the glandular enlargements characteristic of 
the active stages of the disease) had been the proven 
carrier of syphilis to a healthy person. I came to be- 
lieve fully, in regard to persons who had passed success- 
fully through the so-called primary and secondary periods, 
and so proven by complete absence of primary and sec- 
ondary hyperplasias that treatment was no longer neces- 
sary, that such persons might, if desirable, even be per- 
mitted to marry, with the assurance that, through them, 
transmission of syphilis to wife or child was impossible. 
This doctrine I had taught and practised for a very 
long period, when a case came under my observation 
which, but for a mere chance, had unsettled me on this 
vital point forever. The important lesson which it en- 
forced, namely, to distrust the value of purely clinical evi- 
dence, may be profitably transmitted by the brief extract 
from my note-book which follows : 

Mr. Q., a young lawyer, twenty-five years of age, had 



SYPHILIS AND THE GENITOURINARY DISEASES. 47 

acquired a well-marked initial lesion of syphilis on the 
glans penis. His gland enlargements in the epitroch- 
iean, cervical, and post-cervical regions were charac- 
teristic — his roseola escaped observation, but a classical 
papular syphilide appeared about the fourth month, 
and continued for several weeks. Ulcerations of the 
tonsils and mucous patches on the soft palate and inner 
surface of the cheeks followed, but yielded satisfactorily 
to treatment. 

The gentle but persistent use of mercury internally 
and by inunction had been pursued from the first and 
through a period of twelve months, occasionally com- 
bined with the iodide of potassium. At this time all 
glandular enlargements had disappeared, except a small 
one, the size of a pea, in the right post-cervical region. 
Treatment suspended for three months, when a thin 
diphtheric patch appeared on the right side of the 
tongue, with slight induration.* Treatment resumed, 
mercury, with iodide of potash. Patch on the tongue 
faded slowly out in about a month, but was replaced 
by another, on the opposite side, which continued 
about the same time, cervical gland not perceptibly 
changed. A series of mercurial baths, and a course 
of Zittman's decoction, covering nearly three months 
longer : gland now scarcely felt. Patient very anxious 
to marry, but was advised to wait a full year. The 
next six months passed without any new development. 
Gland very small, but still recognizable, when the 
patient, now in good general health, married on his 
own responsibility. 

One year after marriage the wife gave birth to a fine, 
healthy-looking boy. During the fifth month of lacta- 
tion, the wife had scrofulous abscess of the neck (in- 
herited tendency), which alarmed the husband (fearing 
syphilis) exceedingly. She recovered under simple 
treatment, and relief from nursing. Child healthy up 

* I have known patches similar in appearance to result, in certain cases, 
from the use of the iodide of potassuim, to pass off when the remedy was 
discontinued, and again to return when it was resumed. I have also 
seen patches of the same appearance in the mouths of persons habituated 
to the use of tobacco, where no history of syphilis could be ascertained. 



48 PRACTICAL CLINICAL LESSONS ON 

to third year, when it died from tubercular meningitis, 
following- scarlet fever. No salient evidences of syphi- 
litic taint. Fear that his old trouble had been in some 
way connected with his child's death made the hus- 
band very unhappy, and he frequently expressed the 
fear that he had contaminated or might yet contami- 
nate his wife, to whom he was tenderly attached. 

In November, 1870, Mr. Q. complained of some 
swelling and soreness over the right tibia. A gummy 
tumor was found presenting, the size of half a horse 
chestnut. The nature of it explained, he was put on a 
mild mercurial, with large doses of the iodide of potas- 
sium, which resulted in its entire disappearance within 
a month. Both husband and wife continued healthy 
up to October, 1871, when one morning he called, in 
great distress, to say that his wife had some sores in 
her mouth, resembling those of his early syphilitic 
trouble. I did not hesitate to assure him that this was 
simply impossible; that his disease, if any trace of it 
remained, was beyond the fear of contagion. The 
spotless character and chaste deportment of his wife 
made me sure there could be no other danger, and I 
comforted him accordingly. 

What was my surprise, on seeing her, to find not 
only several characteristic mucous patches in her 
mouth, but, on further examination, to discover four or 
five mucous tubercles — one on the inner border of the 
thighs, and the others on the right labium. I was 
forced to acknowledge to the unhappy husband that he 
was right, and we could only conclude, contrary, to all 
my assurance and belief, that his old taint had been the 
cause. 

Here was a dilemma. I could not suspect the wife. 
I could not accept the contagion from a source which 
stultified all my conclusions, teaching, and experience. 
I was wretched. The husband was wretched, but re- 
signed, desiring only, if the knowledge of it was not 
necessary to her recovery, that I should keep the secret 
from his wife. She was serene. After a few weeks' 
medication, and not unfrequent painful applications of 
caustic to the mucous tubercles, I thought she was toa 



SYPHILIS AND THE GENITO-URINARY DISEASES. 49 

serene. I asked and received permission from the hus- 
band to tell his wife what her trouble was, if I thought 
it best. My manner to her was changed ; from being 
sympathetic and considerate, it became brusque and 
reserved. An explanation was finally demanded. I 
evaded the issue. After a little dexterous fencing, the 
source of her troubles was flatly claimed. Ignorance 
of my meaning was feigned. 

I explained the only possible causes of her disease, 
and said she had been married too long to suspect her 
husband. She promptly replied that he was "as pure 
as the sun." I then told her if she would give me her 
confidence, I would protect her — if not, would lay the 
matter before her husband (who was not supposed to 
be aware of the nature of the disease). Then came 
tears — reproaches — and finally, in a tempest of wo- 
manly indignation, she bade me leave, forever. I left, 
disheartened and in disgrace ; but, before I was well 
on my way downstairs, I was recalled, and amid tears 
and sobs she confessed. A yachting excursion ; an 
unexpected night at sea ; exposure with an old lover : 
and all this about three months before. A letter was 
subsequently received from him full of regret that he 
had discovered himself syphilitic, and inquiring if he 
had been so unfortunate as to have communicated the 
disease to her. 

The subsequent progress of this instructive case was 
not peculiar. The lady made an apparently complete 
recovery in about a year. After another year she again 
became pregnant — was delivered of a healthy child, 
now living — but died of puerperal fever the third week 
after her confinement. 

In carefully reviewing this history it will be observed 
that while it is seen to be no exception to the rule that 
tertiary lesions are not contagious, it will show how 
easily they may achieve the credit due to the active 
manifestations of syphilis. 



50 PRACTICAL CLINICAL LESSONS ON 



LESSON V. 

Early Differential Diagnosis — The Earliest Recognizable Evidence of 
Syphilis in Local Cell Accumulation, and Progressing until Character- 
istic Nutritive Disturbances Occur — Neither Inflammation nor Ulcera- 
tion Essential Features in the Results of Syphilitic Inoculation — 
Lesions of whatever Kind may Receive a Syphilitic Inoculation and 
Heal as Quickly and Perfectly as if no such Inoculation had Occurred 
— Immediate Decision in such Cases impossible — Delay until the long- 
est Interval of Known Latency between Exposure and Development 
of Syphilis has Occurred necessary to a Positive Opinion in Cases of 
Doubt — Induration of the Initial Lesion Noninflammatory — Inflam- 
matory Induration Yields to Local Treatment which renders Specific 
Induration more Permanent — Physical Characteristics of Specific In- 
duration — Value of " Confrontation" in Cases of Doubt — Cases Illus- 
trative of Danger of Mistaken Diagnosis. 

EARLY DIFFERENTIAL DIAGNOSIS. 

The characteristic, and only constant, feature of all 
lesions, during the active stages of syphilis, is shown by 
microscopic examination to consist in a localized cell 
accumulation. 

Consideration of the nature and behavior of this ma- 
terial will afford intelligent aid, in a differential diag- 
nosis, between the initial lesion of syphilis, in its early 
period, and solutions of continuity from other causes. 
As far as shown, syphilis is primarily a process of cell 
growth and accumulation, so rapid that it interferes 
with healthy tissue growth, by obstructing the processes 
of nutrition and development. Not of necessity inter- 
fering to the extent of causing death of tissue, but of 
impairing its vitality, and thus causing it to break 
down more rapidly under influences which favor so- 
lutions of continuity. Hence we have presenting, as 
characteristic initial lesions of syphilis, either a neo- 
plasm, dense, insensitive, and covered with unbroken 
and apparently normal cuticle or mucous membrane, 
or, from the causes above mentioned, some one of the 
various characteristic solutions of continuity associated 
with the initial lesson of syphilis. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 5 1 

In addition to the foregoing characteristic lesions, we 
may also find early local disturbance, in various forms 
and from various causes, associated with the beginnings 
of syphilitic cell accumulation, but presenting no feat- 
ures characteristic of syphilitic inoculation. 

The known fact, however, that syphilitic infection 
not unfrequently follows a wound of inoculation, which 
heals promptly, and with no subsequent solution of 
continuity, is sufficient to prove that neither INFLAM- 
MATION nor Ulceration are essential features in the 
results of a syphilitic inoculation. 

Thus, wounds, abrasions, broken vesicles, pustules, 
or ulcers may receive a syphilitic inoculation, and pro- 
gress or heal as if no such inoculation had taken place. 

It is then evident that wo positive differential diagnosis 
can be made at once between lesions which will be fol- 
lowed by syphilitic infection and those which will not. 
A positive decision cannot be rendered until after such 
interval, from latest exposure, as may be required to 
develop some characteristic cell accumulation, either 
on the site of' the lesion or in the adjacent lymphatic 
channels and glands. 

This interval is recognized by all authorities as a 
clinical fact, and is characterized as "The Period of In- 
cubation of Syphilis" 

The term was invented in accordance with a belief 
(formerly prevalent) that the virus of syphilis was a 
mysterious impalpable influence. That this, having en- 
tered the system at a given point, instantly permeated 
the fluids and solids of the entire organism. It then 
accumulated by " a kind of germination" until the point 
of " saturation" or extreme limit of tolerance, was 
reached. This event was announced by a peculiar and 
characteristic action, at the point of entrance of the 
virus, which was termed the Chancre. 

It is plain, however, that such a view of syphilitic in- 
fection can have no support, if we accept the view of a 
cell degradation, and a systematic syphilitic infection, 
in accordance with known histological, physiological, 
and pathological laws. 

It is then to the local conditions, at the point of inocu- 



52 PRACTICAL CLINICAL LESSONS ON 

lation, that, we must look for the earliest evidences of 
syphilitic action. This is afforded, at first, through the 
microscope, by discovery of a densely packed non-inflam- 
matory cell accumulation which steadily increases until 
it is appreciable to the ordinary touch. The same cell 
accumulation is also seen to occur in the lymphatic ves- 
sels connecting the initial lesion with the adjacent lym- 
phatic glands. These vessels are not unfrequently found 
obstructed and indurated, and, like knotted cords, the 
size of a crow's quill or larger, often easily traceable to 
their gland termination. The associated blood-vessels 
are never narrowed or interrupted from this cause.* 

The local induration of a suspected lesion, however^ 
is not positive evidence of syphilitic action. Cell accu- 
mulation sufficient in degree to produce well-pronounced 
induration may result from irritation of a simple lesion. 
Thus, an herpetic vesicle, or pustule, even a simple abra- 
sion, through friction from clothes, or from applications 
of caustics or astringents, may become indurated suffi- 
ciently to raise grave suspicions of syphilis. 

Induration in such cases is always the result of in- 
flammatory action. 

The induration of syphilis is essentially non-inflamma- 
tory. The differential diagnosis is aided by means used 
to combat the inflammatory condition. Under the influ- 
ence of rest and local sedatives the incidental induration 
is promptly dissipated; in the initial lesion of syphilis Xkie 
induration is made more salient. Sometimes, though 
rarely, the induration is quite obscured by a slight local- 
ized serous effusion, which gives it a bluish appearance. 
This I have observed in several cases where the lesion 
was on a finger. The same condition quite frequently 
succeeds well-marked indurations near the fossa glandis, 
and is so persistent as to become a valuable diagnostic 
mark. 

The induration may be said to be characteristic when 

* The only recognizable cell accumulation in syphilis is confined to the 
lymphatic system. If, during the period of so-called incubation, the 
syphilitic influence has found access to the general circulation, no evi- 
dence of it has ever been discovered in the condition of blood-vessels, or 
of the blood, or in the conditions or sensations of the person so affected. 



SYPHILIS AND THE GENITOURINARY DISEASES. 55 

insensitive, dense, and resistant, like cartilage. If 
pressed between the thumb and ringer it becomes ex- 
sanguinated, and like in appearance to the tarsal carti- 
lage, when the eyelid is turned back. 

Even this most positive evidence of syphilis cannot 
be accepted as conclusive. The induration of a com- 
mencing epithelioma simulates it very perfectly, and, if 
an open lesion, its secretion under the microscope pre- 
sents appearances almost identical. In summing up 
the whole matter, we are forced to confess that a final 
decision in any given case is not warranted, until some 
other evidence is present besides the appearance and 
character of the local lesion. 

In all cases, where possible, the person from whom 
syphilis may have been acquired should be carefully ex- 
amined. 

In making such examination, search not only for the 
initial lesion, but for each of the possible secondary mani- 
festations. Even when such are found, it must be borne 
in mind that a breacli of surface on the person exposed 
is essential to the acquirement of syphilis, and that this 
surface must be brought into CONTACT with the syphilitic 
secretion, either directly or mediately. So that while the 
presumptive evidence furnished by confrontation is often 
strong, it is not necessarily conclusive. 

The following cases will serve to illustrate the impor- 
tance of caution in arriving at conclusions in regard to 
the true nature of venereal lesions : 

Case I. Mr. T., aged twenty-three, on the fourteenth 
day after his first and only connection, noticed a slight 
urethral discharge. Under the microscope this was 
found to be distinctly purulent. No pain on urination. 
Meatoscope showed the mucous lining of the urethra 
deeply congested for half an inch. Beyond this there 
was no purulent secretion ; appearances normal. The 
difficulty was, evidently, not gonorrheal. A sypliilitic 
inoculation was suspected. Examination of the woman 
with whom he had connection showed her to be passing 
through the active stages of syphilis. No initial lesion 
was found; but the inguinal, epitrochlean, and cervical 
glands were characteristically enlarged. Several mucous 



54 PRACTICAL CLINICAL LESSONS ON 

tubercles were discovered within the vulva ; one in the 
cervical sulcus, and three on the os tinea. Besides these 
there was a double row around the anus, eroded and 
secreting pus freely. In the presence of such evidences 
of syphilis, it seemed impossible that the young man 
could have escaped infection. The urethral discharge 
was probably caused by a syphilitic inoculation which 
had not yet produced a well-defined initial lesion. Ingui- 
nal glands of both sides slightly enlarged. Treatment 
for syphilis deferred (much against the patient's wish) 
until evidence of syphilis should become more positive. 
The urethral discharge gradually declined and disappeared 
entirely in about a month. Up to the present time (four 
years from date of exposure) patient has not had the 
slightest evidence of syphilitic trouble. 

Case II. Mr. H., aged thirty, had a suspicious con- 
nection in May last. On the third day following he 
noticed several small pimples on his prepuce. Fearing 
venereal disease, he consulted his family physician, who 
at once pronounced the trouble a simple herpes. A mild 
lotion was recommended. Under its use all evidences 
of disease disappeared within a few days, and the patient 
was assured, in the most positive manner, that he was 
free from disease. June ioth, four weeks after the sus- 
picious connection (and more than two after he had 
been pronounced free from disease), the patient was 
brought to me by his physician for an opinion in regard 
to a small, hard, eroded nodule on the former site of 
the herpes. Inguinal glands, on corresponding (right) 
side, characteristically enlarged. My belief that the 
nodule was an initial lesion of syphilis was strongly ex- 
pressed, and the gentleman was put upon a mercurial 
course. A month later he called, presenting a well- 
marked roseola, with the usual secondary gland enlarge- 
ments. His wife, who accompanied him, had an indu- 
rated initial lesion on the lower border of the meatus 
urinarius and well-marked inguinal enlargement. 

Case III. Mr. W. V. No unusual trouble until two 
and one half months ago, when ten days after a suspi- 
cious connection he noticed a small sore on the right 
side of the penis. He consulted a surgeon, by whom 



SYPHILIS AND THE GENITO-URINARY DISEASES. 55 

he was informed that he had a " soft chancre" that he 
would quickly destroy it by application of nitric acid, 
and further, that there need be no fear of subsequent trouble. 
The cauterization was made, was repeated several times, 
at intervals of three or four days ; healing finally taking 
place in about three weeks. Patient had connection 
with his wife the night previous to receiving the sur- 
geon's opinion that he had a cJiancroid; no connection 
since. 

This gentleman called upon me to ascertain the cause 
of apapulo-pustular eruption which was confined to the 
face and neck. I at once recognized it as svphilitic ; 
examined the cicatrix of the so-called cJiancroid, and 
found it distinctly indurated. Gland enlargements of 
elbow and neck, all well pronounced and characteristic. 

In answer to an anxious inquiry as to the possible 
infection of the wife, I was obliged to admit the possi- 
bility of such a calamity. He assured me that she had 
been, and was then, perfectly well in every respect — 
" except that she had some little swellings in the right groin; 
jwt the least pain." An examination of the lady on the 
following day disclosed characteristic gland enlarge- 
ments, not only in the groin, but in the arm and neck. 
No search was made for the initial lesion. She was put 
upon constitutional treatment for " a form of leucocy- 
themia" and remained in blissful ignorance as to the 
nature of her own and her husband's trouble. 



56 PRACTICAL CLINICAL LESSONS ON 



LESSON VI. 

Progress of the Syphilitic Infection — Course of the Disease beyond the 
Point of Inoculation — Infecting Cells Following the Course of the 
Lymph Vessels Carried by the Lymph Current to the Lymphatic 
Glands — Detention in the Glands from Mechanical Causes — No Evi- 
dence yet of Constitutional Disease — Recent Painless Gland Enlarge- 
ments Strong Presumptive Evidence of Syphilitic Infection — Final 
Passage of the Diseased Cells or Germs into the Receptaculum Chyli, 
and from thence into the General Blood Current — The Period Inter- 
vening between the Inoculation and the Entrance of the Disease 
Germs into the General Circulation termed the Initiatory Period of 
Syphilis. 



PROGRESS OF THE SYPHILITIC INFECTION. 

The term Contagion has been used to designate the 
act by which, through cell contact, the syphilitic influ- 
ence is conveyed from a diseased to a healthy person. 

By means of the influence thus communicated, pro- 
liferation and accumulation of degraded cells, at the 
point of original contact (or inoculation), are claimed 
to result in the establishment of the initial lesion of 
syphilis, or chancre, in its various forms. 

The course of the disease beyond this point is indi- 
cated, a priori, by the known fact* that all integumen- 
tary and cellular tissue are pervaded by lymph spaces 
and channels, which lead more or less directly into 
lymphatic vessels, and that the lymph current is con- 
stantly flowing from the tissues toward the lymphatic 
vessels and the glands in which they terminate. 

Therefore a degraded germinal cell (syphilitic) intro- 
duced into the tissues (as by an inoculation), unless 
carried directly into the interior of a blood-vessel, must 
(itself, or its vitiated descendants) of necessity sooner 
or later be carried along by the lymph current to and 

* Strieker's Human and Comparative Histology, Sydenham ed., vol. i. 
pp. 307 et seq. 



SYPHILIS AND THE CENITO-URINARY DISEASES. $7 

into the gland of connection."* All clinical observations 
confirm this view : first, in the discovery of indurated 
lymphatic vessels leading from the point of inoculation 
to the gland in connection ; second, by the subsequent 
enlargement and induration of such glands ; third, their 
acceptance as a necessary sequence of the inoculation, 
and as positive proof of the nature of the disease. 

The process through which the syphilitic influence 
thus gradually advances and finally invades the general 
system is termed the process of Syphilitic Infection. 

The progress of the syphilitic infection^ from the date 
of its genesis at the point of inoculation to its charac- 
teristic appearance in the glands nearest the point of 
inoculation (the glands of connection), varies in different 
persons, from causes not thoroughly settled, but which 
are indicated in note on page 96. 

The degraded cell elements, then, effecting an en- 
trance into the substance of the lymphatic gland, are 
here detained by the peculiarities of the gland struc- 
ture, and perhaps by other inhibitory influences, for a 
period varying, in different instances, from twenty to 
sixty days. This period is recognized by all clinical 
observers, and has been described as the second incuba- 
tion of syphilis. It is certain, however, that no syphi- 
litic influence has yet been discovered in the general 
blood current during this period, and there is sufficient 
reason to suppose that the diseased elements are con- 
fined to the glands of connection, and those intervening 
more deeply between these and the thoracic duct.f 

* " The wandering red blood globules mostly again return into the cir- 
culation through the lymphatics. The wandering white blood corpuscles 
probably return into the circulation in the same way." — Wagner's 
Manual of General Pathology, Am. ed., p. 151. 

f A similar inhibitory influence, exerted by the lymphatic glands in 
cancerous diseases, is cited by Virchow. in his Cellular Pathology, Am. 
ed., p. 221, with the following- explanation: "We can account for this 
by no other supposition than that the gland collects the hurtful ingredi- 
ents absorbed from the breast, and thereby for a time affords protection 
to the body.'" 

It has been suggested that if the disease were really so localized, 
prompt enucleation of the initial lesion and of the affected glands might 
prevent general infection. It must be remembered that the infective 
cells, each of which is potent to act as a starting-point for systemic infec 



58 PRACTICAL CLINICAL LESSONS ON 

The glands of connection become gradually enlarged, 
apparently through the proliferation and accumulation 
of cells in their interior. 

When the initial lesion is located upon the genital 
apparatus, on the glands or on the body of the penis in 
the male, or on the labias or within the vulva in the 
female, the lymphatic glands of the groin become en- 
larged, so that, as a rule, several may be distinctly 
recognized by the touch, varying from the size of a 
small pea to that of a large bean. Sometimes these 
enlargements are apparently confined to the side cor- 
responding with the initial lesion — sometimes to the 
opposite side ; usually, however, the glands of both 
sides are more or less enlarged. Hard, nearly or quite 
painless, and movable, their gradual accession within 
two or three weeks after a suspicious venereal exposure is 
strongly indicative of syphilitic origin, without regard 
to the character of the local lesion. If this is present 
and indurated, the syphilitic character of the trouble 
is no longer doubtful. It must, however, be borne in 
mind that glands enlarged through the influence of 
scrofula cannot be with certainty distinguished from 
those of syphilitic origin. 

They are found in the same locations, and, though 
usually less positively indurated, are still sufficiently so 
to prevent certain diagnosis. When the initial lesion is 
on the lips or in the mouth, the submaxillary gland is 
affected. Wherever situated, it is always the glands of 

tion, are not only present in untold numbers at the point of inoculation, 
but that (as shown by Beisiadecki's microscopic lesearches) the walls of 
the intervening lymphatic vessels are lined if not packed with them. 
Hence any proposed surgical extirpation of the disease must imply the 
entire removal of all the lymphatic connections of the initial lesion and 
the glands of connection. A procedure not only without sufficient prom- 
ise of benefit at this stage of the infection, but even at the earliest date 
after inoculation, the necessary ignorance as to the degree of implication 
of the lymph spaces and vessels in the vicinity of the inoculation would 
in all probability render all such means of preventing the spread of the 
infective processes of uncertain value. 

Early excision of the initial lesion may, however, be found to modify 
the intensity of the subsequent general infection. My own experience in 
twelve cases of excision during the past eight years would warrant this 
inference. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 59 

connection {i.e., those nearest to the seat of inoculation) 
which are involved. Such enlargements are called 
syphilitic buboes. 

The complete freedom from true inflammatory action 
which has been shown to characterize the induration of 
the initial lesion of syphilis, and the lymphatic vessels 
in connection with it, is equally characteristic of the 
enlargement and induration of the associated lymphatic 
glands. When attaining sufficient size to interfere with 
freedom of motion of a part, or where from any cause 
they are subjected to undue pressure, a degree of ten- 
derness may result. From the same cause inflamma- 
tion and even suppuration may occur in highly scrof- 
ulous subjects. Such accidents, however, are excep- 
tional, and do not materially lessen the diagnostic value 
which attaches to recent and painless enlargement of 
lymphatic glands. 

The progress of the syphilitic infection, which has 
been steady and persistent from the moment of inoc- 
ulation to the engagement of the nearest lymphatic 
glands, appears now to be arrested. Gradual increase 
in their size and density alone indicates the activity of 
the infective process, until, after a period (varying in 
different instances from twenty to forty days), evidences 
of constitutional infection may appear. 

Access from the surface to the general blood current, 
through the lymphatic spaces and vessels, necessitates 
passage, 1st, through the gland in immediate connec- 
tion; 2d, through any other glands or vessels which 
may intervene between them and the great lymph 
channels ; passage from thence into the general blood 
mass is immediate. 

Thus, the delay between appreciable implication of 
the glands of connection and earliest evidences of con- 
stitutional syphilis is explained in accordance with 
known histological and physiological laws. Hence, it 
is only after a time sufficient for the passage of the 
diseased elements through the natural barriers, the 
lymphatic glands, to the general blood channels that 
systemic infection can take place. 

With this view oi the progress of the syphilitic infection, 



60 PRACTICAL CLINICAL LESSONS ON 

the interval between the date of inoculation and the 
introduction of the diseased elements into the general 
circulation may be appropriately termed the initiatory 
PERIOD OF SYPHILIS. 



SYPHILIS AND THE GENITOURINARY DISEASES. 6l 



LESSON VII. 

Varieties and Complications of the Initial Lesion of Syphilis — The Indu- 
rated Papule — 2. The Dry Scaling Patch— 3. The Chancrous Abrasion 
— 4. The Saucer-shaped, Non-suppurating Chancre, with Indurated 
Base and Edge— 5. The Elevated, Moist, Velvety Papule — Modifica- 
tions of the Foregoing — 1. The Mucoid Chancre — 2. The Inflamed or 
Suppurating Chancre — 3. The Phagedenic or Gangrenous Chancre — 
Modifications of the Initial Lesion of Syphilis from Implantation of 
Chancroid or other Secretions upon it. 

(1) The initial lesion of syphilis begins by a process 
of Undue Growth and Multiplication of normal 
germinal cells, induced by contact (through a lesion of 
mucous membrane or integument) with Diseased or 
Degraded cells derived from a person suffering from 
Syphilis. 

(2) Cells thus generated accumulate at the point of 
initiation, in a circumscribed portion of the surrounding 
and underlying tissue, and also in the walls and interior 
of the blood and lymph vessels of the tissue so impli- 
cated, and thus form a characteristic neoplasm, which 
is termed the Initial Lesion of Syphilis — of which there 
are five characteristic forms, namely : 

(1) The Indurated Papule. 

(2) The Dry Scaling Patch. 

(3) The Chancrous Abrasion. 

(4) The Saucer-Shaped Non-Suppurating Chancre, 
with indurated base and edge. 

(5) The Elevated, Moist, Velvety Papule. 
And as modifications — 

The Mucoid Form. 

The Inflamed or Suppurating. 
. The Phagedenic or Gangrenous. 

Also modifications arising from implantation of the 
Virus of Chancroid or other Vicious Secretion, upon the 
Initial Lesion of Syphilis of any one of the above-named 
forms. 

The initial lesion of syphilis may be situated at any 



62 PRACTICAL CLINICAL LESSONS ON 

point on the surface of the body, or it may be concealed 
within the orifice of the meatus urinarius, the anus, or 
the mouth. 

The differences in form of the initial lesion of syphilis 
are the legitimate and direct results of interference, to 
a greater or less degree, with the circulation of the tis- 
sues, at or beneath the point of initiation, of the abnor- 
mal cell-growth. Thus, in regard to the first-named 
form : 

(i) The indurated papule is a dense neoplasm in the 
cellular tissue, movable under the skin, and hence not 
materially impeding its functions. Complete absorp- 
tion of this morbid growth may take place, and the 
organism become thoroughly contaminated with syphi- 
lis, without the occurrence of any open lesion. 

(2) The dry scaling patch always occurs upon integu- 
ment, and the cell accumulation is diffused and quite 
superficial, producing an induration which to the touch 
is like parchment ; hence the term "parchment indura- 
tion'' applied to this lesion. Interference with the 
circulation in this case is not sufficient to prevent the 
evolution of the epidermis, but its development is im- 
peded, and layers of dry epidermic scales cling to its 
surface, giving it a characteristic scaly appearance. 

(3) The chancrous abrasion occurs upon an indurated 
papule, which by peripheral cell-growth has come to 
involve the circulation of the cutaneous or epithelial 
structures to the extent of rendering them friable and 
easily abraded. Imperfect evolution of the underlying 
cell elements results in a free shedding of the superficial 
layers from the moist surface of the lesion. Under the 
microscope these are seen to be like laminated epithelial 
scales, and constitute a significant mark of chancrous 
abrasion. 

(4) The saucer-shaped non-suppurating chancre, with 
indurated base and edge. In this form a characteristic 
loss of tissue has taken place (almost entirely at the 
expense of the adventitious cell-growth), through the 
continuance and extension of the causes which produce 
the chancrous abrasion ; loss of tissue, as in that case, 
also occurring, not through the suppurative or ulcera- 



SYPHILIS AND T,HE GENITOURINARY DISEASES. 63 

tive process, but by that which Virchow has termed a 
necrobiosis (death from altered life), that is, from a grad- 
ual obstruction to the processes of nutrition of the 
affected part. The secretion of this form of initial 
lesion is scanty, free from pus, and presents under the 
microscope the squamous epithelial elements found in 
the secretion of the chancrous abrasion. 

(5) The elevated, moist, velvety papule, is neither 
more nor less than the previously described lesion, 
" The saucer-shaped non-suppurating chaiicre, with indu- 
rated base and edge" upon which the granulation tis- 
sue of Billroth has been developed. This tissue is 
described in Billroth's " Patholog} T ," Am. ed., p. 93, 
under the head of ^Proliferating fungus granulations" 
He says, " The most frequent cause of the development 
of such granulations is any local impediment to healing, 
such as rigidity of the surrounding skin, so that the con- 
traction of the cicatrix is difficult." This rigidity in 
the case of the moist velvety papule is caused by the 
characteristic induration of syphilis, always associated 
with this form of initial lesion. 

We shall consider next the modifications to which the 
different forms of initial lesions are subject. 

(1) The mucoid chancre, is that modification of the 
moist velvety papule, which arises from the occurrence of a 
diphtheritic membrane, or deposit, upon its surface, giv- 
ing it the appearance of that secondary or constitutional 
manifestation of syphilis known as the mucous papule. 
This modification usually takes place coincidently with 
the appearance of mucous papules or patches in other 
localities. The induration associated with the initial 
lesion, thus modified, and its entire absence in the mu- 
cous papule ^ will constitute the distinguishing difference 
between these lesions. 

(2) The inflamed or suppurating chancre. In any 
of the open initial lesions subjected to persistent irri- 
tation from friction of clothes, repeated coition, appli- 
cation of caustics, alcoholic excess (especially in the 
scrofulous and debilitated), an inflammatory action may 
be set up. This soon results in pus formation, and 
a more or less active necrosis, so like in character to 



64 PRACTICAL CLINICAL LESSONS ON 

that occurring in chancroid, that errors in diagnosis are 
easy. The, now purulent, secretion of the chancre is 
found to be contagious, producing by auto-inoculation 
a sore, identical with true chancroid, thus further ob- 
scuring the differential diagnosis. Previous history, 
and the induration more or less distinctly marked, will 
usually be sufficient to indicate the true character of 
this lesion. 

(3) The phagedenic or gangrenous chancre. In 
certain cases of the inflamed or suppurating initial 
lesion the indurated tissue becomes livid in color quite 
suddenly, and exhales a peculiar sickening odor, an- 
nouncing the occurrence of gangrene. This results 
from arrest of the vascular supply to the induration, 
through an aggravation of the causes which led to the 
antecedent necrobiosis. This view is sustained by the 
known influence of mercury in arresting the destruct- 
ive process thus set up in the initial lesion, while 
in any other form of gangrene the influence of this 
drug is known to be pernicious, and also from the fact 
that the loss of tissue is usually limited to the indu- 
ration. When the death of tissue occurs by molecular 
continuity, the lesion is said to be Phagedenic ; when 
the induration sloughs out en masse it is called GANGRE- 
NOUS. The influences which tend to convert the in- 
flamed or suppurating initial lesion into the phagedenic 
or gangrenous are predisposition to suppuration from 
any cause, constitutional dyscrasia, alcoholic excess, low, 
irregular life, etc. 

All forms of the initial lesion in syphilis may be modi- 
fied and more or less obscured by the occurrence of 
ulceration from any cause upon the site of syphilitic 
inoculation. 

No surface changes at the point of entry of the syphi- 
litic virus or principle can affect the course of the 
syphilitic infection after the disease germ has passed 
into lymph channels (spaces or vessels) below that sur- 
face. The characteristic local evidences of syphilitic 
infection may, however, be modified and more or less 
completely obscured by accidental lesions, such as her- 
pes, resulting from contact with vicious vaginal and 



SYPHILIS AND THE GENITOURINARY DISEASES. 65 

uterine secretions, or other causes, or by contact of the 
lesion of syphilitic inoculation with the virus of chan- 
croid. 

Such lesions pursue their course uninfluenced by the 
syphilitic cell-proliferation previously inaugurated, and 
may thus obscure diagnosis until evidences of constitu- 
tional infection are manifest. 

Hence, wherever the possibility of a syphilitic infec- 
tion is present, any breach of tissue, whether a simple 
abrasion or fracture of mucous membrane or integu- 
ment, or any vesicle or pustule, whether from general 
or venereal causes, whether healing as if simple or pur- 
suing the characteristic course of the chancroid, then 
in such case, opinions in regard to the presence or absence 
of the contagium of syphilis must be reserved until 
such time, from the date of latest exposure, as will equal 
the longest period known to obtain between inoculation and 
syphilitic infection, as indicated by induration of the local 
lesion and enlargement and induration of the adjacent 
lymphatic glands. This is not less than forty days. 



66 PRACTICAL CLINICAL LESSONS ON 



LESSON VIII. 

Treatment of the Initial Lesion of Syphilis by Excision — Description of 
Operation and Subsequent Care — Constitutional Treatment also Es- 
sential — Local Measures where Excision is not Applicable — Relief from 
Accumulated Cell Material causing the Chancre occurs only through 
Fatty Metamorphosis — Mercury the most Efficient Agent both Locally 
and Internally — Forms, Doses, and Modes of Administrations — Treat- 
ment by Inunction — General Care — Treatment of Modifications — I. 
Mucoid Form — 2. Inflamed or Suppurating — 3. Gangrenous — Treat- 
ment of Concealed Initial Lesions — Treatment to be Continued after the 
Cure of the Initial Lesion — Increase or Diminution of the Induration a 
Barometer for Treatment — Enlargement and Induration of Lymphatic 
Glands nearest to Initial Lesion the First Positive Evidence of Progress 
of the Infection. 



TREATMENT OF THE INITIAL LESION OF SYPHILIS. 

First, by Excision. Whenever a well-determined initial 
lesion is situated in loose tissue (integument or folds of 
prepuce in males, or of the vulva in females) the earlier 
removal by excision is accomplished the better. Not 
with the expectation of preventing constitutional infec- 
tion (which, as a rule, is inevitable before the local lesion 
is discovered), but as far as possible to remove a focus 
of dissemination for diseased elements, and to diminish 
the danger of conveying disease to others. 

The infective neoplasm, whether under sound skin or 
appearing in any one of the forms or modifications 
previously described (except the inflamed or suppurat- 
ing), should be removed entire. The resulting wound 
heals, as a rule, by first intention. Even when the in- 
duration is large, little if any deformity remains after 
cicatrization. Practically the indurated tissue is a for- 
eign body, and its thorough removal requires the sacri- 
fice of but little of the surrounding healthy structure. 
Favorably situated open initial lesions of long standing 
may be promptly cured in this way. 

For the performance of this operation first cleanse 
the parts thoroughly by gentle bathing in warm water. 



SYPHILIS AND THE GENITOURINARY DISEASES. 6? 

In all open lesions apply a solution of carbolic acid of a 
strength of one part of the acid to forty parts of water, 
after which raise the mass of induration between the 
forefinger and thumb, and encircle it firmly at the base 
with a bit of fine silver or malleable iron wire. The in- 
durated part may be separated from the normal tissue 
in the same way by compression between the arms of a 
bent probe, being careful to include the entire indura- 
tion. 

Now with a narrow, sharp-pointed bistoury pierce 
the tissues at the centre beneath the compressing wire 
probe, and cut well under and out, including all the 
indurated and a little of the sound tissue of that side. 
This effected, from the place of beginning, cut out in 
the same way on the opposite side. Be assured by 
careful examination that every portion of the neoplasm 
is removed, then introduce interrupted sutures of silk 
or silver wire at intervals of a quarter of an inch or less. 

The patient should be kept in the recumbent position, 
the parts constantly wet with carbolated water, until 
the third day, when on removal of the sutures union by 
first intention will, as a rule, be found to have taken 
place. 

The resulting cicatrix may indurate, to a greater or 
less degree, but rarely, if ever, to the extent of inducing 
a solution of continuity. 

In no case does this procedure lessen the necessity 
for Constitutional Treatment. The indurated papule, 
when so located that excision is unadvisable (as on the 
glans penis, or involving the tissues of the corpora), may 
be subjected to applications of the oleate of mercury 
(six per cent solution), or any correspondingly mild 
mercurial ointment. When the mucous membrane or 
cuticle covering the induration is abraded, or at any 
stage of simple necrobiosis, dusting the surface with dry 
calomel and protecting it with a thin layer of dry lint 
is then serviceable. Calomel, in combination with lime- 
water, in the proportion of a drachm to the pint {lotto 
nigra), or bichloride of mercury, half a drachm to the 
pint of lime-water (lotio flava), are both much esteemed 
as applications to the open initial lesion. The tissue 



68 PRACTICAL CLINICAL LESSONS ON 

metamorphosis and absorption, which are requisite for 
the removal of the syphilitic neoplasm, are most readily 
induced by the internal administration of some one of 
the various mercurial preparations. In all forms of the 
initial lesion the chief obstacle to resolution or healing- 
is the mechanical interference to nutrition occasioned 
by accumulated cell-growth. Its removal must occur 
through the process known as fatty degeneration. The 
most active and reliable agent in effecting this and in 
promoting the necessary subsequent absorption and 
elimination, is mercury ; hence the internal administra- 
tion of some mercurial preparation is essential in all 
well-determined initial lesions. The proto-iodide (so- 
called green iodide) of mercury, in pill, one quarter grain 
to one grain, three times a day. The biniodide in one 
thirtieth to one twelfth. The bichloride in doses of 
from one thirtieth to one twelfth of a grain. The mass, 
hydrargyrum, from two to four grains, and may be 
judiciously combined with iron. A favorite formula, 
and one which I usually prescribe, consists of two grains 
mass, hydrarg. with one of the exsiccated sulphate of 
iron. This may be made into a pill, and if intestinal 
irritation ensue one fourth grain of the watery extract 
of opium may be added. This pill was first suggested 
to me by the late Dr. Bumstead, and is sometimes 
known as pil. Duo or Duplex. Any of these forms of 
mercury may be administered (in suitable vehicles), in 
the dose deemed judicious for the presenting case, three 
times a day (increasing the dose if necessary to the 
limit as above indicated), until the constitutional influ- 
ence of the drug is manifested by a spongy and sensitive 
condition of the gums or a slight mercurial odor in the 
breath. 

In introduction of mercury into the system through 
inunction of the mild ointment of mercury, where this 
drug is not well borne by the digestive apparatus — a 
dram rubbed in morning and evening — changing locality 
each application — thus, in right axilla in morning, left 
at night; then under left knee, then right; then right 
axilla again, and so on, until the desired effect on gums is 



SYPHILIS AND THE GENITOURINARY DISEASES. 69 

produced; then reduce amount so as to keep just below 
this point. 

The mercurial impression should be maintained as 
nearly as possible at this point until complete absorption 
of the local neoplasm has been effected. Its further em- 
ployment will be considered in the Lessons on Treat- 
ment of General or Constitutional Syphilis. 

Cleanliness, freedom from friction and irritation from 
all other causes, simple diet, and abstinence from alco- 
holic stimuli, are necessary to the most favorable results 
in treatment of the Initial Lesion as well as all other 
forms of syphilis. 

In regard to the modifications of the initial lesion of 
syphilis : The mucoid form requires, in addition to the 
constitutional treatment previously described, the appli- 
cation of the solid argentum nitratis (or some other 
caustic), sufficient only to destroy and subsequently to 
repress the exuberant granulations. The inflamed or 
suppurating initial lesion, requires rest and opiate or 
sedative dressing, as the lotto plumbi et opii, in the pro- 
portion of five grains each to the ounce of water ; or 
the powdered iodoform, simple, or with an equal part of 
tannic acid, which seems to deodorize in some degree, 
and possibly increases the efficiency of the iodoform. 
In the gangrenous form the powdered iodoform is effi- 
cient as an antiseptic. 

Poultices of powdered charcoal are also of value, but 
the internal administration of mercury must not be 
neglected while the gangrenous action is limited to the in- 
duration. Passing beyond this point, prompt and thor- 
ough cauterization under ether, with the fuming nitric 
acid or the galvano or the gas cautery, should be done 
so as completely to destroy the tissues involved in the 
destructive action. Opium is of great value in subdu- 
ing pain in these cases, as well as on account of its bra- 
cing effect on the nervous system. Occurring in debili- 
tated or highly scrofulous subjects, as is usually the 
case, attention should be given to general support, by 
generous diet, quinine, and iron. The potassio-tartrate 
of iron, in fifteen- to twenty-grain doses every three or 



JO PRACTICAL CLINICAL LESSONS ON 

four hours (as recommended by Ricord), seems to exert 
a specific influence over gangrenous conditions. 

It must not be forgotten that healing and apparent 
cure of the initial lesion does not mean cure of syphilis. 
After disappearance, more or less complete, the indura- 
tion may return. Not unfrequently it may be observed 
to increase or diminish in apparent sympathy with the 
progress or abatement of the constitutional disease. 
From this fact the local induration has come to be con- 
sidered by some as a reliable barometer, by which the 
effect of general treatment may be appreciated. The 
duration of the initial lesion varies greatly in different 
cases, sometimes disappearing within a few weeks, and 
with it every trace of induration ; at others it continues 
as an induration, more or less distinctly marked, 
throughout the active stage of the constitutional infec- 
tion. Enlargement and induration of the lymphatic 
glands, nearest in connection with the initial lesion, 
constitute the first positive evidence of the progress of 
constitutional infection. 

Concealed initial lesions (as within the meatus uri- 
narius or the anus) may be treated with bougies or 
suppositories medicated with opium, salicylic acid, or 
iodoform. 



SYPHILIS AND THE GENITO-URINARY DISEASES, Jl 



LESSON IX. 

On the Early Manifestations of Syphilis — The Organism not Infected at 
once, but by a Gradual Process, through Normal Physiological Chan- 
nels — No Constitutional Evidence of the Disease at any Point until at 
least Thirty or Forty Days after Inoculation — Roseola of Syphilis — 
Clinical Case — Roseola of Syphilis shown to be the Result of Sympa- 
thetic Nerve Disturbance like Simple Roseolas, and not Caused by 
the Local Accumulation of Syphilitic Material — Pigmentation Due to 
Exudation of the Coloring Matter of the Blood and not to a Specific 
Material — Clinical Case Illustrating the Papular Eruption of Syphilis 
and its Comcomitants — Supernumerary Epitrochlear Gland — Mucous 
Patches Simulating Diphtheria — The Secretions of all Lesions of this 
Stage of Syphilis Inoculable — Note in Regard to the Contagion of Syphi- 
lis — Importance of Care to Prevent the Same — The Necessity of an 
Artificial Port of Entry a Great Security against the Acquirement of the 
Disease — Illustrative Cases. 



EARLY CONSTITUTIONAL FORMS OF SYPHILIS. 

The cases to which your attention is now invited are 
in illustration of the acute stages of syphilis, and these 
include all the manifestations of the disease during 
which a contagious element pertains to it. The first 
manifestation, the " initial lesion" in its varied forms, has 
already been considered. The adjacent gland enlarge- 
ments, resulting from the same processes of cell prolife- 
ration and localized accumulation, have been seen to be 
an inseparable adjunct in every case, but they have 
been present without the least evidence of constitu- 
tional disturbance. No sensation of the patient, nor 
any recognized physical sign, suggests anything more 
than a local disease. Notwithstanding the claim of cer- 
tain authorities that syphilis is a constitutional disease 
at the moment of inoculation, and that, as Billroth puts 
it, the " organism is infected at once,"* all the scientific 
research yet made, goes to prove that the disease pro- 
gresses by individual infection of germinal cells, from 

* Billroth's Surgical Pathology. Am. ed., p. 386. 



72 PRACTICAL CLINICAL LESSONS ON 

the point of inoculation, along the lymphatic channels, 
one of the chief offices of which, is to carry germinal 
material from the tissues into the general blood cur- 
rent. That their progress is slow and is obstructed 
by the lymphatic glands is made manifest, in every case, 
by the enlargement of all those immediately interposed 
between the point of inoculation and the great lym- 
phatic reservoir, the receptaculum chyli, and by the fact 
that, until at least thirty or forty days after the inocu- 
lation, there is absolutely no evidence of the disease 
having reached the general blood current. In other 
words, it may be said, that, up to such time, the infection 
is confined to the locality of the inoculated point and 
the glands in immediate connection with it, and cannot 
yet be said to be a constitutional disease. At about the 
sixth week, however, an eruption presents, as the first 
evidence that the disease has found access to the system 
at large. This is well shown in the patient now before 
you. He has a history of suspicious venereal connec- 
tions — of one in particular about two months since. 
He accidentally noticed a small abrasion on the inside 
of his prepuce, near the " bridle" on the left side, which 
bothered him for several weeks, but was never of suf- 
ficient account to consult a surgeon about, and finally 
healed. Yesterday, after getting quite heated in a run- 
ning match, his face became spotted with red blotches, 
and, on going to bed, he found his body more or less 
covered with them. Here you have a fine specimen of 
the roseola of syphilis. Its history and advent are char- 
acteristic. There is a distinct thickening easily felt at 
the point referred to as the site of the abrasion. It is 
not as characteristic as in many cases you have seen, 
but is sufficient, when taken in connection with the 
history, the distinctly enlarged inguinal glands, and the 
roseola, to characterize the initial lesion of syphilis. 

The glands of the cervical region are also enlarged, 
so that we may accept the case as a classical one of 
early constitutional syphilis, which I have been accus- 
tomed to designate, on account of the tendency to 
localized accumulation in the glands at a distance from 
the point of inoculation, and in the skin at a later period, 



SYPHILIS AND THE GENITOURINARY DISEASES. 73 

as the period of general infection and localized cell accumu- 
lation* 

In its general appearance this exanthem is not un- 
like a slight eruption of measles. Pressure with the 
finger in the syphilitic roseola causes the color to dis- 
appear completely when the eruption is recent, as in 
the present instance, but when it has existed for some 
weeks a brownish or copper-colored stain is left. The 
longer the eruption remains, the more likely it is to 
leave its characteristic trace, namely, a coppery stain, 
unaffected by pressure. The color of this stain here, 
as well as in other syphilitic eruptions, is usually con- 
sidered valuable as a diagnostic mark of syphilis. With 
this exception, however, it is not materially different 
from an idiopathic roseola. Like the latter, it appears 
suddenly, often during or following any exercise which 
gives a violent impetus to the circulation of the blood, 
such as rowing, dancing, or running. 

Pain or other premonitory symptom is not necessarily 
associated with it. Sometimes it is slight, consisting 
only of a few pale spots ; while again it is profuse and 
highly colored, and occasionally slightly elevated. But 
it never develops into any other form of lesion. Beyond 
a reddish blotch, it is never more than a copper-colored 
stain ; and even this stain, the only really salient point 
of difference between simple roseola and that which is 
thus seen to be associated with the advent of constitu- 
tional syphilis, will be shown to result from simple 
causes. It is true that this eruption is popularly 
accepted as syphilitic, in the sense that it is caused by 
the local presence of syphilitic material, and is to be 
gotten rid of through the same means by which the 
specific cell accumulations (forming papules in the skin 
and mucous membranes) at a later stage of the disease 
are eliminated. I believe, however, that this can be 
shown to be an error, and that this roseola, like all the 
other roseolas, is the result of a purely functional dis- 
turbance. Baumler says of it : " In every syphilitic 

* For further information as to the causes of the ' ' Roseola of Syphilis, " 
see Otis on the Physiology, Pathology, and Treatment of Syphilis, p. 17. 
New York: Putnam. 1881. 



74 PRACTICAL CLINICAL LESSONS ON 

efflorescence there is a circumscribed dilatation of blood- 
vessels, together with a certain amount of exudation of 
white-blood cells into the sheaths of the vessels merely, 
and into the surrounding tissue. The greater the de- 
gree of stasis the more abundant will the exudation of 
red corpuscles be ; and it is the alteration of the coloring 
matter in these red globules which imparts to the color of 
the syphilidcs, after they have remained for some time, their 
yellowish or brownish shades. These shades are more 
distinct in proportion as the congestion of the vessels 
thereby occasioned recedes, and they are more pro- 
nounced the longer the stasis has continued. In the 
same way any efflorescence or its immediate vicinity, 
or scars following ulcers on the lower extremities, not 
due to syphilis, may assume this color. Long-continued 
dilatation of capillaries and stasis of the blood are all 
that is necessary to produce pigmentation." 

Case II. Here is another case presenting the charac- 
teristic developments of syphilis at a somewhat later 
period, and affords us an excellent opportunity of a 
further study of its leading features. The initial lesion 
is said to have occurred four months ago, and one month 
after the suspicious connection. It healed in a couple of 
weeks. During its presence the patient says it looked 
like a simple sore, but there is still here a little knot of 
induration, situated in the loose tissue of the prepuce, 
indicating the character as well as the locality of the 
lesion. We find also well-marked enlargement of the 
lymphatic glands of the groins, and particularly below 
Poupart's ligament, on both sides, which latter is quite 
unusual at so early a period of the infection. You 
also observe very plainly an eruption on the forehead. 
It is papular in character, and is characteristic of the 
secondary eruption of syphilis, the first eruption being 
a roseola, which usually comes on at a period varying 
from six weeks to two months after the appearance 
of the initial lesion. Then, after another interval of 
about the same length of time, we get the second erup- 
tion, which is papular in character ; the first — the roseola 
— being macular, and occasionally slightly elevated. 
The second eruption has been described by authors as 






SYPHILIS AND THE GENITOURINARY DISEASES. 75 

of a raw-ham color or a coppery hue. It is rosy in 
color when it first makes its appearance, but grows 
darker and darker, until finally the papule passes away, 
leaving a distinct reddish or copper-colored stain. You 
will observe in this patient that the eruption is very 
prominent and wide-spread over the back. Some of 
the papules are surrounded by a little exfoliated epi- 
dermis, which is known as the " collarette of Biett," 
and is considered characteristic of a syphilitic lesion 
by some writers. It is simply an exfoliation of the 
epidermis of the surface of the papule, seen most dis- 
tinctly at its base, and is dependent upon modified 
nutrition, caused by infiltration of the papules with cells. 
These interfere with the vascular supply of the part, 
and we get the exfoliation here exactly in the same way 
that we get it at the point of initial lesion — from accumu- 
lation and concentration of cells in that locality. When 
this exfoliation is present on a papule, it affords an ad- 
ditional proof of the syphilitic character of the trouble. 
You will, however, see cases of psoriasis where the 
scales have been brushed off. which so nearly simulate 
the syphilitic papular eruption that it is impossible 
to distinguish between them ; and without other aid 
we are often obliged to wait further developments in 
order to make the diagnosis. Fortunately, however, 
for the diagnosis, but unfortunately for the patient, we 
nearly always have, at the time of the occurrence of 
this papular eruption, other lesions which aid us in 
making the diagnosis. The glandular enlargements in 
the groins, of the neck, and also in the epitrochlean 
spaces — sometimes one, sometimes all — ought to be 
well marked by this time. You will observe here on 
the neck a gland which can be seen at quite a distance 
— it is so much enlarged. There is a group of enlarged 
and indurated glands just behind the sterno-cleido-mas- 
toid muscle, and another farther back on either side. 
Here in the right epitrochlean space there is an en- 
larged gland about the size of a large pea, and what I 
do not remember to have ever found before, viz., an- 
other gland about two inches higher up, only a trifle 
smaller than the first. Quite often the epitrochlean 



j6 PRACTICAL CLINICAL LESSONS ON 

gland, instead of being in the little space above the in- 
ternal condyle of the humerus, is found an inch or two 
or three inches higher up, between the borders of the 
biceps and the triceps ; but a supernumerary gland, as 
in the present instance, is very rare. 3y this time also 
papules occur in the mucous membrane, and these are 
especially characteristic, there being nothing else which 
resembles them, unless possibly in psoriasis. When 
syphilitic papules occur in mucous membrane they 
usually soon become eroded and covered with a diph- 
theritic pellicle to greater or less extent. 

Mucous patches — really papules — in the mouth are 
characteristic of syphilis in its acute stage, and are 
present in a marked degree in this case. The mouth and 
the tongue are literally covered with them to an extent 
which you rarely see. These papules, which appear on 
the tongue, throat, and mouth, are superficial, and so 
flat that they are scarcely if at all raised above the sur- 
rounding surface or spread over an area varying from 
the size of a pea to that of half a dollar or larger, hav- 
ing often a gray or pearl colored diphtheritic edge which 
occasionally festoons the edge of the soft palate, form- 
ing a very characteristic and unmistakable mark of 
syphilis. Some time ago I was called to see a man 
who was supposed to be suffering from diphtheria. I 
found him surrounded by his family, who were in great 
solicitude about him. On looking into his throat I saw 
this characteristic festooning of the palate, and did not 
hesitate a moment in making up my mind that the 
trouble was syphilitic. Soon having an opportunity to 
speak to the young man alone, I discovered that he had 
syphilis, although he had not before been aware of it. 
The mucous patch is also liable to occur between the 
toes or any place where there is habitual moisture. 
Just at the verge of the anus is a favorite seat for it ; 
and knowing this fact, examination of this locality will 
often help you out in the diagnosis of an obscure case. 
The mucous papule, from its prominence when on the 
skin or semi-mucous membrane about the anus, is usu- 
ally called a mucous tubercle, and is quite characteris- 
tic in this patient, as you see. 



SYPHILIS AND THE GENITO-URINARY DISEASES. JJ 

You should bear in mind that the secretions of all 
lesions during this stage of the disease are inoculable, 
and one suffering from it may communicate the disease 
from the secretion of any open lesion upon the body 
or on the mucous membranes:* You will understand, 

* The active period of syphilis, thus shown to be marked by exces- 
sive localized cell proliferation, is equally characterized by the contagious 
property attaching to cells thus generated. Inoculation of the blood, and 
of the secretion of all open lesions during the active period of syphilis, 
has been found capable of communicating syphilis promptly to healthy 
persons. 

The physiolo ical secretions — milk, saliva, urine, perspiration, tears, 
and spermatic fluid — have not been proven to be agents of syphilitic infection. 
Where apparently so, in many cases, syphilitic lesions of the mouth or 
breast have been found to account for the seeming inoculability of the 
•saliva or of the milk. Repeated experiments* have been made by inocu- 
lation of the spermatic fluid of a person proven to be in the active stage 
of syphilis upon healthy persons, with absolutely negative results. In 
this we find confirmation of our position that the contagious property of 
syphilis is not an entity, an independent virus, pervading all the tissues 
and fluids of the organism, but that it is confined to the white-blood or 
tissue-building cells,' and in this view we readily see how the physiologi- 
cal secretions above mentioned, which do not contain them, are found 
also to be free from the contagious property of syphilis. 

Thus far the only distinguishing feature which has been recognized 
between normal embryonal cells and cells which make up the accumula- 
tions characteristic of the active stage of syphilis is the possession by 
the latter of the contagious property ; in other words, a contagium — the 
power of setting up in other cells, through simple contact, the same dis- 
position to rapid proliferation which the so-called syphilitic cells are 
known to possess. The direct result of this hasty proliferation, as far 
as we have yet been able to discover, is not a destructive action. It is 
simply and only what we should naturally expect from hastily generated 
normal material in excess of the necessities of growth and repair. In 
representative, uncomplicated cases it remains for a time obstructing the 
tissues by its presence, and then through purely normal processes, often 
of necessity set into operation by crowding of the newly formed cells, 
prolonged pressure, and consequent innutrition, and also from general 
causes it undergoes fatty degeneration, and is in this way finally elimi- 
nated from the affected organism. \ 

Baumler virtually supports this view:}: when he says of the active stage 
of syphilis, " If there are only a few local deposits, the elimination of the 
virus may be so much in excess of its production that the organism is 
gradually freed from it. This takes place in the majority of cases, and at 
the expi?-ation of eighteen months or two years the infection is entirely ex- 
hausted." 

*Dr. Mireur, of Marseilles. Annales de Dermatologie et de Syphilographie, No. 6, 
tome viii., 1877. 

t A fatty metamorphosis, entirely like that which occurs pathologically, occurs in the 
normal condition of the organism. Wagner, p. 305. 

$P. 247 of Ziemssen's Cyclopaedia, Am. ed., vol. iii. 



78 PRACTICAL CLINICAL LESSONS ON 

therefore, the importance of warning the patient having 
such lesion of the danger of communicating the disease 
to others by contact. A pencil, a pipe, a spoon, a knife, 
or other article introduced into the mouth where mu- 
cous patches are present, some of this secretion con- 
tained in the saliva drying upon it, and afterward 
coming in contact with an abrasion of the lips of an- 
other person, will communicate syphilis to that person 
as positively and certainly as would a syphilitic vene- 
real connection. From this you may see that syphilis 
is not necessarily a venereal disease, but any one ex- 
posed in the ways above referred to is liable to receive 
it, in which event it will follow the same course as if 
acquired by venereal connection. The great security 
which we all have against the accidental acquirement 
of syphilis is, that it requires an artificial port of en- 
trance — a fracture of the skin or of the mucous mem- 
Mr. Hutchinson, of London, in speaking of the contagious property 
which attaches to the emasculated white-blood cell, which we call pus, 
says, "All living pus is contagious. . . . I mean," he further says, "that 
all pus cells possess the power of setting up, when transferred to another 
home, if that home be a suitable one, a kind of inflammatory action 
similar to that from whence they themselves had originated." This, 
we know, results in the almost immediate death of cells in localities so 
contaminated. In the case of the germinal cells contaminated by con- 
tact with the syphilitic cells, however, this results only in a hasty genesis 
of cells, a too rapid production, which prevents their highest develop- 
ment; they fall by the way, are heaped up, undergo fatty degeneration, 
and are or may be eliminated. Nor is it alone in diseased cells that a 
contagious property is claimed to reside. Rindfleisch, an eminent Ger- 
man authority, in speaking of embryonal cells coming up from the tissue 
juices for the regeneration of mucous membranes, says of such cells that 
"they become epithelial cells only by coming into contact with such. We 
must believe," he continues, "in a kind of epithelial infection." This, 
he says also, " must of course just as well obtain when embryonal forma- 
tive cells approach an existing epithelial stratum, as when, conversely, 
epithelial elements approach embryonal formative cells." If this be 
true, it at once becomes evident that the contagious property is not of 
necessity a virus ; and it must I think be suggested, in this view of the 
matter, as equally evident that the so-called virus of syphilis is simply a 
manifestation of that property or personal influence inherent in all cells, 
whether healthy or degraded, and which is as subtle and intangible, as 
incapable of material demonstration, as the influence which one mind 
exerts over another. Is it not then possible that the mischief which 
syphilis does is rather the result of an interference with the normal pro- 
cesses, through hasty development brought about by this influence, than 
of the action of a specific virus? 



SYPHILIS AND THE GENITO-URINARY DISEASES. 79 

brane for its inoculation. Otherwise, sooner or later, we 
should all be likely to have it, for we could not come in 
contact with people who have syphilis without danger 
of getting it at every turn. But fortunately it requires 
an abrasion, an open port of entry. It is rarely through 
the ordinary affectionate relations between children and 
parents, brother and sisters, that communication of the 
disease takes place. If, however, an abrasion exist upon 
the lips of both parties the disease may be communi- 
cated from the one to the other by a kiss. I have often 
known this to occur in the venereal kiss, but never by 
'the ordinary kiss of courtesy and family affection. But 
the liability to communicate the poison to an innocent 
person should be borne in mind by every one passing 
through the acute stage of syphilis. We must also bear 
in mind the fact that the disease may be transferred 
from a syphilitic to an innocent person, by the physi- 
cian, by the use of the spatula, carelessly laying it down 
after examining a syphilitic mouth, allowing the secre- 
tions to dry upon it, then introducing it into the mouth 
of another patient before properly cleansing it. This 
is especially liable to occur if the second patient be a 
child, as by its restlessness during the examination, a 
lesion of the mucous membrane of the mouth may be 
made by the instrument. All instruments in use about 
the mouth, throat, or teeth should be carefully cleansed 
and passed through the flame of an alcohol lamp imme- 
diately after use, and certainly before use upon another 
person, because syphilitic lesions may be present, 
although unrecognized. Several well-authenticated 
cases have come under my observation where syphilis 
has been contracted in the mouth from lack of proper 
care in this regard. Mucous papules are very often 
present in the vagina or on the os uteri of females suf- 
fering from acute syphilis. In the Independent Practi- 
tioner for March of this year may be found a report of 
no less than eight cases of syphilis of the finger, in 
medical men, acquired through vaginal examinations 
or attendance on syphilitic women during childbirth ; 
and since sending in that report I have seen two similar 
cases occurring in the resident medical staff of one of 



80 PRACTICAL CLINICAL LESSONS ON 

the hospitals of this city. All of these cases were fol- 
lowed by constitutional evidences of syphilis. It is 
scarcely necessary to say that the early recognition and 
local treatment of mucous papules, patches, or tubercles, 
is one of the important duties attaching to the manage- 
ment of acute syphilis. Another characteristic lesion of 
the disease consists in the presence of scabs in the hair, 
as seen in this patient. The discovery of scabs, in this 
locality, sometimes enables us to make a positive diag- 
nosis, when otherwise we would be in doubt. Alopecia, 
or falling of the hair, is one of the common, though 
not constant, concomitants of this stage of the dis- 
ease. It is readily accounted for on the same principle 
that explains the exfoliation of the epidermis in the 
syphilitic papules. The crowding of newly formed 
cells in the vicinity of the hair-bulbs interferes with 
their nutrition. It is not at all unusual for a patient to 
lose his hair completely, including his eyebrows and 
whiskers ; but this baldness is not permanent, since on 
proper treatment, directed to the removal of this super- 
fluous cell material, the hair is renewed. We find that 
any or all of the foregoing lesions of syphilis may be 
absent, and the patient yet go through a disease which 
shall be recognized as syphilis. In other words, this 
disease varies in its intensity as much as any other, and, 
except the enlargement of the lymphatic glands, none 
of the conditions which you see in this patient are 
necessarily essential to the progress of syphilis. This 
is a very marked case, one in which we find present 
more than the usual number of characteristic lesions or 
manifestations. 



SYPHILIS AND THE GENITO- URINARY DISEASES. 8 1 



LESSON X. 

The Treatment of Syphilis in the Acute Stage — Not Addressed to a Vague 
and Conventional Diathesis, but to the Removal of the Material shown 
to be Creating Disturbance — All Lesions of Active Syphilis the Result 
of Local Crowding of Cells at Various Affected Points — The Difficulty 
to be Remedied a Mechanical One — Inquiries as to the Best Method 
of Removing the Superfluous Cell Material — Fatty Metamorphosis 
Alone Capable of Effecting this — Different Methods of Producing Fatty 
Degeneration and Elimination — Mercury Proven to be the most Po- 
tent Agent— Reasons for Using it in Small Doses Long Continued — 
Directions in Regard to the Use of Mercury in its Various Forms — 
Internal Administration — External Use — Diet in Syphilis — Effects of 
Rum and Tobacco in Retarding the Cure of Syphilis — Prof. Willard 
Parker's Advice. 

The treatment of this, as well as all cases of syphilis 
during the acute stage, will be addressed to the removal 
of the material which is causing the trouble. That is, to 
the superfluous cell growth or accumulation. The same 
material that we find in the initial lesion, and the same as 
that which we find embarrassing and enlarging the gland 
structure. The same as in the papule. The same as in 
the mucous patch. The same as in the papules which 
form the scabs which occur in the hair. These lesions 
are all brought about and kept up by one and a single 
condition, namely, that resulting from an abnormal local 
proliferation and accumulation of germinal cells. This 
fact has been substantiated by repeated microscopical 
examinations of all lesions of acute syphilis. Conse- 
quently, the cause of all the several conditions or lesions 
of active syphilis being the same, — that is to say, an 
accumulation of this embarrassing cell material, — the 
treatment is simple, and the same for all, having simply 
for its object the removal of such material. 

The question as to how this shall best be effected 
leads us to consider first, the nature of the material we 
desire to be rid of. This has been proven beyond a 
question to consist of human germinal cells, in no known 
respect different from normal germinal cells, except that 



82 PRACTICAL CLINICAL LESSONS ON 

they are the product of a proliferation more rapid than 
that process under normal conditions. Microscopically 
they cannot be distinguished from the cells which are 
proliferated and accumulated to repair loss of normal 
tissue brought about by ordinary causes. Secondly, 
What are the means and processes by which healthy 
cell-material, exuded in excess of the necessities of 
growth and repair, is removed ? The answer is simply 
that, the necessary process, is a fatty metamorphosis. 
Through this, alone, any living material, normal or ab- 
normal, must pass before it can be eliminated from the 
living organism. The means by which it may be 
effected are various : ist, pressure ; 2d, innutrition ; 3d, 
various external agents and internal remedies, which by 
experiment have been found efficient in producing or 
hastening fatty degeneration or metamorphosis of tissue. 

First, in regard to pressure: The effect of pressure 
in producing this result, is recognized in its known influ- 
ence, as a surgical measure, in reducing and dispersing 
abnormal growths. This is also recognized in its ten- 
dency to spontaneous disappearance, after a time, with- 
out treatment, of the cell-accumulations of syphilis. The 
tendency of all syphilitic lesions is toward recovery. 
The necessary pressure exerted upon any local cell 
accumulation in the tissues would tend toward its re- 
moval by fatty degeneration. 

Second, in regard to innutrition. Withholding of 
necessary food produces fatty degeneration of the tis- 
sues. The starvation cure was at one time, especially 
in Germany, in great repute as a cure for syphilis. The 
sweating cure. The long popular and much vaunted 
cure by cathartics, diuretics, etc., through profuse 
drinking of decoctions of sarsaparilla, senna, and differ- 
ent woods, can now be recognized as influential through 
their capacity to hasten fatty metamorphosis. But the 
remedy of greatest acknowledged value, in the treat- 
ment and cure of syphilis, for the past two hundred 
years, and up to the present day, is mercury, and this, it 
is well known, is also the most efficient agent in produc- 
ing fatty metamorphosis of living material. Healthy 
persons quickly emaciate, all kinds of tissues break 



SYPHILIS AND THE GEMTO-URINARY DISEASES. 83 

down, under its continuous excessive use. In the 
salivation it then produces, the characteristic foetid 
odor has been found due to the decomposed fat which 
results from the fatty degeneration it causes. In point 
of fact, every remedy which has ever had a substantial 
reputation, as of value in the treatment of syphilis, will 
be recognized, a priori, as one of greater or less power 
in inducing fatty metamorphosis. If then we find in 
syphilis, as the characteristic and essential factor of 
ever} 7 lesion, an accumulation of superfluous cell mate- 
rial, sufficient in degree to embarrass the functions of 
the vessels or tissues implicated, we have good reason 
to introduce the remedy which, par excellence, is known 
to be potent in removing it, namely, mercury. And if we 
consider that this remedy is also in highest repute from 
a clinical standpoint, we are warranted to proceed in its 
administration with the expectation of the best possible 
results. The manner of its use, the size of the dose, its 
frequencv, and time of continuance only remain to be 
settled. Clinical experience in the administration of 
mercury has taught the fact, now accepted by all recent 
recognized authorities in matters syphilitic, that small 
doses of mercury continued for a very long period, say 
from one to three years, constitute the best treatment 
for the most efficient and permanent eradication of syph- 
ilis from the system of a person afflicted with that dis- 
ease. This applies to any and ever} 7 form and manifes- 
tation of it during the acute stage, which stage may 
be said to cover a period varying in different cases from 
one to three, possibly four, years. The hastily generated 
cell material which has been described as the essential 
element in the production of the different manifestations 
of syphilis, lacks the healthful vitality to enter effect- 
ively into the composition of normal tissues. It is pres- 
ent only as obstructive material, and from its presence 
as such is already subject to the mechanical influences 
which tend toward its dissolution. It may then be ac- 
cepted as more readily affected by remedial measures 
calculated to induce fatty metamorphosis of living mate- 
rial, than such material generated and developed under 
normal conditions. Hence a smaller amount of mercury, 



84 PRACTICAL CLINICAL LESSONS ON 

for instance, would be necessary to effect its removal 
from the affected organism than would be required to 
produce a like effect on healthy tissues. Such an amount 
then as would cause the speediest removal of the imper- 
fect or syphilitic material, without damaging the healthy 
constituents of the body, would constitute the highest 
ideal of an antis} r philitic treatment. Hence we can 
accept from an intelligent and philosophical standpoint 
the position which has heretofore been only taken from 
a clinical or empirical view of the matter, viz., That 
small doses of mercury, long continued, constitute the most 
effective and judicious mode of treatment of syphilis during 
its active stage. 

Beginning then with small doses, of whatever prepa- 
ration of mercury we decide to administer, in a given 
case, we increase the amount until we find the constitu- 
tion of the patient being affected, evidenced by the pres- 
ence of softness of the gums, or a little red line about 
them. When that occurs, we know we are getting to a 
point of affecting the healthy structures of the body, and 
then the dose is reduced until just that point is reached 
at which the patient can be carried through without any 
disturbance of the alimentary canal or of the salivary 
apparatus. In the case of this patient, then, we should 
commence by giving small doses of mercury, gradually 
increasing the quantity until the point of tolerance is 
reached, and keep it there. Any of the preparations of 
mercury may be given. We will begin, say, with the 
protoiodide, a quarter of a grain, three times a day for 
two or three days ; or lest the patient should, as is the 
case with some, be peculiarly sensitive to the influence 
of mercury, we may begin by giving only two pills a 
day for two or three days, and then add a pill at a time 
as long as he shows no evidence of disturbance from it, 
and, when the highest point of tolerance is reached, 
continue the dose. Sometimes blue mass with iron is 
used, pills containing two grains of the mass, hydrarg. 
with one grain of the exsiccated sulphate of iron — two 
£0 four daily until the desired impression is produced, 
'and continuing usually about three per day throughout 
the desired period. In all these cases I may remark 



SYPHILIS AND THE GENITO-URINARY DISEASES. 85 

that iron is indicated because the health is usually more 
or less below par. Therefore, when giving the proto- 
iodide of mercury, I am also in the habit of giving the 
dialyzed iron, in doses of ten or fifteen drops, three 
times a day. The biniodide of mercury may be given 
in doses of a sixteenth of a grain, or any other of the 
preparations of mercury may be administered in suit- 
able doses, the object being simply to get the gradual 
and positive effects of the drug. It may be adminis- 
tered by external means, using a small quantity of mild 
mercurial ointment, say the size of a filbert, rubbing it 
in under one knee one night, under the other knee the 
next morning, under the axilla the next night, and so 
on, using it night and morning. There have been those 
advocating the hypodermic use of a solution of the bi- 
chloride of mercury, but this is a method of adminis- 
tering it which, while I have used it, I do so no longer, 
and do not recommend it, finding other quite as efficient 
and more agreeable ways of introducing mercury into 
the system. Mercurial baths or fumigations may also 
be used for the same purpose. 

Whatever be the form of mercurial you decide upon 
employing, your treatment should be conducted accord- 
ing to the principles I have mentioned for all the lesions 
or manifestations of the acute stage of the disease. 
Whether it be of the skin, of the- mucous membrane, or 
whether it be a syphilitic iritis, an inflammation of the 
iris (which is caused really by a papule occurring at 
that point, that is, an accumulation or aggregation of 
cells). All these conditions or manifestations of syphi- 
lis, I repeat, respond to this systematic method of mer- 
curial treatment better than to any other. The open 
lesions during the acute stage of syphilis, chiefly on 
mucous membrane, the mucous papules, patches, and 
tubercles, before alluded to, in addition to constitu- 
tional measures, require prompt local treatment, espe- 
cially on account of the contagious property of their 
secretion. Daily applications of a strong solution of 
nitrate of silver — forty to sixty grains to the ounce of 
water — or a light brushing over with the solid arg. 
nit. will be found most efficacious in hastening: their 



86 PRACTICAL CLINICAL LESSONS ON 

disappearance. This also applies to ulcerations of the 
tonsils, which sometimes occur during this stage. 

When papules are so situated as to cause annoyance by 
their unsightliness, as on the face or hands, ung. hyd. nit. 
or ung. hyd. prsecip. alb. with an equal quantity of cosmo- 
line, or a ten per cent solution of oleate of mercury with 
equal part of cosmoline may be used as a daily local ap- 
plication with advantage. In the latter case a few drops 
of one of the essential oils will render it more agreeable. 
The diet of the patient should be simple, excluding 
acids, spices, and highly spiced food. Tobacco is par- 
ticularly injurious during the course of this disease, 
from the fact that both smoking and chewing are liable 
to produce irritation of the mucous membrane, and 
when a mucous patch occurs in the mouth it is a very 
difficult thing to heal while its contact with tobacco is 
kept up. It is certainly a very great hardship for per- 
sons who are addicted to the use of tobacco to give it 
up ; but it is very important that they should do so for 
the proper and effectual treatment of this disease. In a 
very interesting note, received not long since from the 
venerable Professor Willard Parker, in which he spoke 
of syphilis, I remember he very quaintly said in regard 
to it, " Some people believe that syphilis is incurable ; 
that is not my belief. When a patient comes to me 
with syphilis I say to him, Do you use tobacco or alco- 
holic spirits? If he says yes, I say to him, You are pos- 
sessed of three devils — syphilis, rum, and tobacco ; if 
you will exorcise two of them, R. and T., I will take 
care of and cure the other ; but if you will not agree 
with me to give assistance in this way, I will not under- 
take your case." I would advise you all to make a note 
of this and remember Dr. Parker's advice. I can assure 
you it fully coincides with my own opinion, particularly 
in regard to the " rum ;" and in regard to the " tobacco" 
also, when the mucous membrane of the mouth and 
throat is affected or predisposed to trouble. 



SYPHILIS AND THE GENITOURINARY DISEASES. 87 



LESSON XT. 

Case I. Clinical Case Illustrative of the Initial Lesion Occurring with- 
out Ulceration — Points of Value in Diagnosis of the same — Treatment. 
Subsequent History — Demonstration of Cure through Birth of Healthy- 
Children — No Evidence of Syphilis in Twenty-nine Years. 

Case II. Initial Lesion of Syphilis without Induration, and without Loss 
of Tissue "Parchment" Variety — Any Degree of Induration may 
Present — Baumler's Views. 

Case III. Saucer- shaped, Non- Suppurating Initial Lesion, with Indurated 
Base and Edge — Description — Concomitants — Treatment — Subsequent 
History — Marriage — No Subsequent Trouble in Fifteen Years. 

Case IV. Initial Lesion of Meatus Urinarius Symptoms — Complicated 
with Apparent Chancroids — Their Occurrence found due to Inflamed 
Initial Lesion — Diagnostic Points — Treatment — Secondary Lesions — 
Initial Lesions Aggravated by Local Irritants — Sexual Indulgence — 
Alcoholic Stimuli. 

CLINICAL CASES FROM MY NOTE-BOOKS, ILLUSTRATIVE 
OF THE VARIOUS FORMS WHICH THE INITIAL LESION 
MAY PRESENT IN CONSTITUTIONAL SYPHILIS, AND OF 
THE VARIOUS LESIONS ASSOCIATED WITH AND FOL- 
LOWING THE SAME: 

Case I. Induration without ulceration. — M. W. ; set. 
29; merchant. June, 1854. History: Never had any- 
previous venereal trouble. Illicit connections with 
various females, at intervals of a week or two, for many 
years ; no suspicion of disease especially attaching - to 
any. Noticed a little abrasion or chafe on the loose tis- 
sue of the prepuce, near the fossas glandis, in the median 
line, which healed in a dav or two under the application 
of a little Goulard lotion. Some three months after, 
during which he had no renewed exposure or any sus- 
picion of trouble, he noticed a small hard painless swell- 
ing on the site of the former abrasion, and some sense 
of fulness in the groins, which attracted his attention, 
when he recognized several little bunches, not before 
observed. Was under the impression that these might 
be due to strain from over exercise, and called to inquire 
if they needed any attention. 



88 PRACTICAL CLINICAL LESSONS ON 

Examination revealed a hard kernel in the cellular 
tissue of the prepuce at the point before noted, movable 
and not sensitive. Lymphatic glands of both inguinal 
regions distinctly enlarged, some size of a small bean ; 
not tender. Tissues of pharynx and soft palate deeply 
congested. Glands along the posterior border of the 
sterno-cleido-mastoid muscle enlarged ; not tender. 

The points of value in arriving at a diagnosis were 
as follows : 

ist. A history of fracture of the skin or semi-mucous 
membrane resulting from a suspicious venereal connec- 
tion. 

2d. Subsequent induration at that point. 

3d. Recent painless enlargement of the inguinal 
glands, or those nearest to the suspected point of inoc- 
ulation. 

4th. Similar enlargement of glands at a distance, as 
the cervical. 

5th. Congestion of faucial region. 

Careful examination failed to discover any eruption 
on the skin or mucous membrane. Not the least pain 
or impairment of general health appreciated by the 
patient. 

Diagnosis. — Syphilis in the so-called secondary stage. 
Allowing twenty-one days as the usual or average inter- 
val from inoculation to induration and enlargement of 
inguinal glands, and forty or fifty days before the subse- 
quent general gland enlargements, it carried the initia- 
tion of the disease -back at least two months, which, taking 
into consideration that the induration was quite as large 
as a small pea when accidentally discovered, warrants 
the conclusion that the inoculation of syphilis occurred 
at the date of the abrasion one month previous, or 
three months from the time of its discovery. 

The patient was put on a mild mercurial course and 
kept under its influence, as indicated by occasional ten- 
derness of the gums (when it was alternated with iodide 
of potassium), for fully two years. The congestion of 
the pharynx continued with but slight change for sev- 
eral months, when a sharply cut and painful ulceration 
occurred in both tonsils. This was treated by occa- 



SYPHILIS AND THE GENITO-URINARY DISEASES. 89 

sional applications of the strong- nitric acid and solid ni- 
trate of silver subsequently. The throat continued con- 
gested for several months longer; no other ulceration or 
eruptive lesion at any point. The induration occurring 
on the site of inoculation did not disappear entirely for 
over a year. At the end of the second year the gland 
enlargements were scarcely perceptible, and the treat- 
ment was discontinued, the patient remaining free from 
any sign of disease for one year after. Then he married. 
Subsequently four children were born to him. At this 
date, September, 1882, twenty-nine years have elapsed. 
Patient and family all living and well. Eldest son, 28 ; 
next, 26 ; next, 20 ; daughter, 10: no one of them having 
in the interval had any recognized manifestation of 
syphilis ; on the contrary, have all been exceptionally 
healthy and robust. 

Remarks. — Evidences of localized cell accumulation 
progressing gradually in the line of the lymphatic chan- 
nels, from the point of inoculation, to the glands in the 
groin, then at a distance, finally involving the tonsils to 
such a degree as to interfere with the processes of nu- 
trition and production of a sloughy ulceration, show 
that the case was unquestionably one of syphilis. It is 
shown, by this case, that syphilis may be characteristic 
without ulceration or recognized general eruption, and 
it will be found in following the history of other cases 
that the ulceration of the tonsils, which in this instance 
was valuable in a diagnostic point of view, is more 
usually absent, and hence is not an essential but an ac- 
cident, without which the foregoing case would have 
been free from all ulcerative lesions. This case forms 
a link in the chain of evidence which goes to prove that 
syphilis is curable, that the contagious element of the 
disease is limited in its duration, and that in this instance 
the limit did not exceed three years. 

Case II. Initial lesion without characteristic induration, 
and without loss of tissue. — Papular eruption. M. L.; 
22 ; printer. Occasional venereal exposures: presented 
with a well-marked papular eruption on the forehead, 
also sparsely scattered over the body, arms, and legs ; 
denied ever having any sore. Inguinal glands en- 



90 PRACTICAL CLINICAL LESSONS ON 

larged and painless ; in cervical region the same. Epi- 
trochlear gland of left arm as large as a marrowfat pea. 
A brownish spot, size of half-dime, was observed on the 
body of the penis, covered with fine bran-like scales. 
Patient first noticed this about two months previously 
as " a little spot of scurf" about one half its present di- 
mensions ; thought it was of no consequence. Integu- 
ment occupied by the spot slightly but distinctly stiff- 
ened, giving an excellent example of what is termed by 
authors the parchment induration, and characteristic of 
a somewhat rare form of the initial lesion of syphilis. 
Patient's general health unimpaired, but had of late suf- 
fered with headache in the evenings, chiefly keeping 
him awake during the early part of the night, and pass- 
ing off without treatment. Diagnosis syphilis. Initial 
lesion of parchment variety. Treatment: B pil. duplex 
(2 grs. mass, hydrarg. and 1 ferri sulph.); one after meals. 

Under this treatment the cephalalgia disappeared 
in the course of a couple of weeks. The eruption on 
the body gradually lost its papular character, leaving 
a coffee stain, which at the end of six months was just 
visible ; glands less in size, but still prominent. Initial 
lesion free from induration and scales, but still of tawny 
color distinctly marking its site. Very slight redness 
at border of gums. On several occasions there had been 
slight sponginess and tenderness, then pills by direc- 
tion, had been suspended for a few days and again re- 
sumed as the tenderness disappeared ; otherwise the 
medicine had not produced any sensible disturbing 
effect. Bowels regular; appetite good ; general health 
perfect. 

Remarks. — Baumler, in speaking of this variety of the 
initial lesion of syphilis, says, " From these cartilaginous 
indurations" (associated with and characteristic of the 
ordinary initial lesion of syphilis) " to the flat paper-like 
thickening of the mucous membrane, where increased 
resistance is perceptible only in feeling of it sideways, 
all imaginable intermediate stages occur ; the one thing 
common to them all, being a dense cellular infiltration 
of the tissue of the cutis or mucous membrane." * 

* Ziemssen, Am. Ed., vol. iii. p. 112. 



SYPHILIS AND THE GENITOURINARY DISEASES. 91 

Case III. Saucer-shaped, non-suppurating initial /csion, 
with indurated base and edge. — H. G. A. ; commercial 
traveller; aged 31. Nov. 15, 1867. Suspicious connec- 
tion about two months previously ; none before for sev- 
eral months ; none subsequently. Thinks that it was 
about four weeks after when he accidentally discovered 
a little " chafe" on the left side of the penis just behind 
the glans. This he treated with simple water dressings 
for a few days, when he saw a physician who pronounced 
it syphilitic. Cauterized it ; gave him a lotion to apply 
on a little lint, and ordered pills to be taken for several 
weeks. 

Under this treatment the " chafe" had gradually in- 
creased in size, and presented the following conditions : 
An ulcer-like lesion about the size of a half-dime ; 
edges slightly elevated, rounded, sloping, forming a 
saucer-shaped concavity; the floor slightly granular; 
very red and clean, and exuding a little transparent 
secretion, which under the microscope was found to 
contain only large epithelial scales. To the touch the 
edge and base of lesion was hard and elastic, and mova- 
ble on the underlying cellular tissue. It represented 
the typical unirritated initial lesion of syphilis often 
known as the Hunterian chancre. The lymphatic glands 
in either groin were enlarged, painless on pressure ; 
several the size of a small bean ; no gland enlargements 
in the cervical region ; no trace of any eruption on the 
body ; throat not congested ; general health good. 

Diagnosis. — Syphilis in the primary or initiative stage. 

Treatment. — Pil. duplex thrice daily ; local application 
of lotio nig. 

Subsequent History. — During the following month the 
patient had a well-marked roseolous eruption, which 
passed off within a few days without in any way affect- 
ing his general health. A group of lymphatic glands 
became enlarged on each side of the neck ; the mucous 
membrane of the throat became deeply congested and 
somewhat sensitive. 

Under the treatment above noted, the local lesion 
gradually healed and the induration slowly diminished, 
but did not disappear entirely for nearly six months, 



92 PRACTICAL CLINICAL LESSONS ON 

and then left a slightly juicy-looking swelling in its 
place, which could be distinguished for fully as much 
longer. 

The mercurial treatment as above noted was con- 
tinued steadily for a full year, the only omission being 
during a few days on three or four occasions, when in- 
creasing to four pills per day the gums became tender; 
otherwise there was no trouble of any sort referable to 
the medicine or the disease. Glands still distinctly en- 
larged. During the second year a combination of mer- 
cury with the iodide of potassium was given (hyd. bin- 
iodid. y 1 ^ gr. ; potass, iodid. grs. vjii.; Mistura biniodid. 
hydrarg.), a teaspoonful three times daily after meals. 
At the end of this year, during which the patient's 
health had been excellent, the gland enlargements in the 
inguinal and cervical regions had entirely disappeared ; 
there was not the slightest trace of syphilitic trouble 
at any point, and the patient was discharged cured. 
Married two years subsequently ; two children, fourteen 
and seven years. August, 1882; no trouble to which 
any syphilitic suspicion could attach during this inter- 
val of nearly fifteen years. 

Case IV. Initial lesion of the meatus urinarius. — H. R. 
Inflamed or suppurating chancre. After a series of 
impure connections a smarting on urination was ob- 
served, and on examination by a physician slight oozing 
of mucus from the urethral orifice. Was treated by 
injections under the belief that he had contracted a 
gonorrhoea. Matters continued about the same for a 
few days, when the discharge became tinged with blood. 
This led to an examination, which revealed a small point 
of ulceration just within the meatus urinarius. On the 
supposition that the trouble was chancroid, the ulcer 
was touched repeatedly with nitric acid and subse- 
quently treated by introduction of iodoform. After a 
persistent trial of this plan for about three weeks, the 
difficulty not only did not improve, but the part became 
very tender and swollen and the discharge profuse and 
purulent, and urination very difficult. Several small 
ulcers at length appeared on the inner surface of the 
elongated prepuce. This was the condition of things 



SYPHILIS AND THE GENITOURINARY DISEASES. 93 

when the patient presented himself for change of treat- 
ment. 

Attention was at once attracted to the dense indura- 
tion of the tissues about the meatus, also to the presence 
of well-marked enlargement of inguinal glans on both 
sides. 

The glans and prepuce were swollen and intensely 
red. An ulceration of ragged character occupied fully 
two thirds of the meatus inferiorly, and extended about 
one third of an inch, as determined by the introduction 
of a small meatoscope (Otis's). Three small sharply cut 
ulcers, the largest size of a split pea, occupied the pre- 
putial opening — apparently chancroids. These had 
occurred over a month from the date of any venereal 
exposure, and more than three weeks from the dis- 
covery of the urethral trouble. This was opposed 
to the supposition that the original lesion was a chan- 
croid. When, however, the well-established fact that 
the initial lesion of syphilis, under prolonged irritation, 
becomes suppurative, and the resulting pus has the con- 
tagious and destructive qualities of pus from a true 
chancroid, the explanation of the occurrence of appa- 
rent chancroids, a month after exposure was easy. 
This was also a suggestion as to the true character of 
the original lesion, and was confirmed by the recent pain- 
less gland enlargements in each groin, as well as by the 
characteristic induration associated with the urethral 
ulcer. The patient was required to keep the recumbent 
position for a few days, and apply a lead and opium 
lotion to aid in reducing the inflammatory complication. 
Iodoform applied to the pseudo-chancroids and to the 
initial lesion, and the patient was promptly put upon a 
mercurial course (pil. duplex, one thrice daily). Under 
this treatment the ulcerations external to the urethral 
orifice healed within a few days, but the urethral obstruc- 
tion, causing by the swelling and induration was so 
increased, that sloughing of the urethra threatened, 
when the meatus was freely divided through the dense- 
ly indurated tissues. Immediate amelioration of pain 
and inflammation resulted. From this time the recov- 
ery from the local troubles progressed rapidly, and 



94 PRACTICAL CLINICAL LESSONS ON 

gave but little further annoyance, although the indura- 
tion remained. In another fortnight the patient called 
to say that his gums were a little tender, and also that 
he had had some diarrhoea for a few days. Evidently 
the mercurial was in excess, and he was directed to dis- 
continue until these troubles had passed, away, Exam- 
ination of his body at this time revealed a well-marked 
roseola, the spots of which, from the size of a half-dime 
to one third that size, were distinct on the breast, back, 
and arms. Several also on the soles of the feet, and 
also on the palms, but none on the face, or back of 
hands. This was a complete surprise to the patient, 
although he had been instructed to look out for it, and 
he was confident that it had not been present more than 
twenty-four hours, and, except for the diarrhoea, ex- 
pressed himself as having felt perfectly well. Enlarge- 
ment of glands in the cervical and epitrochlean regions 
was now distinct. 

Nothing further of moment occurred for the follow- 
ing weeks, and the patient was in fair condition, taking 
three pil. duplex daily ; when at about the middle of 
the third month (from the discovery of his trouble) he 
began to complain of headache at night, keeping him 
awake until nearly morning, then passing off and re- 
turning on the following night, and he complained of 
a general malaise, and this without any recognized 
excess or error in diet. A small superficial ulceration 
was discovered on the right side of the tongue, and 
another about the size of a three-cent piece on the right 
anterior pillar of the fauces. Some few scabs were also 
discovered on the scalp. On again examining his body 
the faint coppery stains of the roseola were seen here 
and there over the body, and in addition to this a 
few red elevated papules, not more than a dozen in 
number, were discovered scattered over the body ; 
none on the face, hands, or feet. 

Pills continued. The superficial ulcerations (mucous 
patches) in the mouth were daily touched with a forty - 
gr. sol. of nit. arg. In a week the patient was in his 
usual condition ; the papules passed off in about a 
month, leaving some slight yellowish stains. No recur- 



SYPHILIS AND THE GENITO-URINARY DISEASES. 95 

rence of mucous patches. Continued the pills up to 
date of departure from town, July 1, 1882, at which 
date he had been under treatment for twelve full 
months, and at the time had no trace of induration 
about the site of the initial lesion, no trace of the 
eruptions, nothing- left to indicate his syphilitic trou- 
ble, except the still easily recognized, though greatly 
decreased gland enlargements in the groin, in the cer- 
vical and right epitrochlean regions. That in the left 
epitrochlean space at time of discovery about the size 
of a pea had quite disappeared. Ordered mist, biniodid. 
for at least six months, and then to report for further 
orders. 

Remarks. — The result of persistent irritation of a sim- 
ple initial lesion of syphilis is well shown in the fore- 
going case. Also the fact that sores simulating true 
chancroids may arise simply from contact with the pus 
from an initial lesion of syphilis, the normal secretion 
from the latter being only composed of serum and the 
debris of epithelial material. 

It will be observed that, in this case, the appearance 
of the roseola was not preceded by any peculiar sensa- 
tion on the part of the patient, while that of the later 
papular eruption was associated with characteristic 
preliminary disturbance. This, however, is in all pro- 
bability due to the gradual obstruction of lymphatic 
glands throughout the system, and not to any special 
influence of the papular eruption; for it will be observed 
that here, as in similar cases, the appearance of the 
eruption did not relieve the malaise of the patient, as 
is the case under similar circumstances in the eruptive 
fevers. It will be observed that this case varies from the 
preceding ones in that the characteristic eruptions of 
the active stage were present. As we proceed it will 
appear that no two cases are quite similar in regard to 
the variety or degree of concomitant manifestations ; 
but it will also be found that in all cases the lymphatic 
gland enlargements play a prominent part, and that, 
as their presence is the most important and significant 
evidence of the presence of syphilis, their gradual and 
finally, their complete disappearance, is the surest evi- 



g6 PRACTICAL CLINICAL LESSONS ON 

dence of the complete disappearance and virtual cure 
of syphilis. Finally, it may be stated in regard to the 
inflammatory complication, present in the foregoing 
case, that this is likely to occur in any initial lesion of 
syphilis from the persistent application of irritants, such 
as nitrate of silver, sulph. copper, etc., or from friction 
by the clothing. Its occurrence is favored by the scrof- 
ulous diathesis, by sexual excitement, and by irregular 
living and alcoholic stimuli. 



SYPHILIS AND THE GENITOURINARY DISEASES. 97 



LESSON XII. 

Clinical case — Phagedenic form of the Initial Lesion and its physical pecu- 
liarities — Treatment by mercurials — Rapid healing under their influ- 
ence — Phagedena of Chancroid influenced unfavorably by mercurials 
— Subsequent history, showing results of insufficient treatment in early 
stage — Early, steady and prolonged treatment the only trustworthy 
means of preventing later lesions of the disease — Inability to bear the 
mercurial treatment very rare — Cures, in properly treated cases, estima- 
ted at 95 per cent. 

Case V. Gangrenous initial lesion, or so-called pha- 
gedenic chancre, followed by mucous patches ; death by 
cerebral softening. — L. K., drug clerk, aged 21 ; of scrofu- 
lous diathesis and dissipated habit ; presented with an 
inflamed ulcer about as large as a three-cent piece, 
shaped somewhat like the figure 8, partly on the glans 
penis (left side), and encroaching upon the fossae glandis, 
and situated upon a densely indurated base. The 
floor of the ulcer, which was apparently about a line 
in depth, was of a yellowish gray color, of a shreddy 
appearance, exhaling the peculiar sickening odor of 
gangrenous tissue. Glands of either groin enlarged and 
hard; no other signs of disease. He gave a history of 
great sexual and alcoholic excess prolonged over several 
weeks ; the discovery of a sore on his glans penis about 
a fortnight previous, and daily touchings with blue 
stone, on his own responsibility. He fancied he was get- 
ting better when he went off on a spree of several days' 
duration, having occasional sexual connections in the 
time. For the last two days there had been considera- 
ble pain, and he had been applying iodoform in powder. 
The induration, which was very dense, extended about 
two or three lines from the edge of the ulcer, where it 
met quite abruptly the swollen tissue surrounding it. 
Diagnosis : gangrenous initial lesion of syphilis. The 
fact that simple sores and also chancroids become indu- 
rated by applications of caustics, and even of simple 
astringents in some cases, was borne in mind ; but the 



98 PRACTICAL CLINICAL LESSONS ON 

recent well-marked and painless gland enlargements in 
the inguinal regions were, when taken in connection with 
the history and condition of the lesion, considered suffi- 
cient proof of its syphilitic origin to warrant the test by 
a mercurial course. The patient was sent to bed, pow- 
dered charcoal poultice, sprinkled with iodoform as dis- 
infectant and sedative, and calomel in T V-gr. doses was 
administered every hour during the day, not continu- 
ing it through the night ; and when i J grains had been 
taken the patient's gums were distinctly tender and 
the medicine was omitted. The slough extended until 
the entire induration was destroyed, it was removed, 
within a few days, and showed a healthy granulating 
surface. The mercurial was continued in the form of 
the proto-iodid, hyd. in pills of half a grain each, and 
healing took place in about a month, leaving scarcely a 
trace of induration, but a soft, juicy-looking swelling, 
about the size of the original lesion, in its place. Some 
swelling and tenderness of the submaxillary glands oc- 
curring, the mercurial was entirely omitted, and the 
patient put upon cod-liver oil and iron. Not seen again 
for nearly six months, when he reported with mucous 
patches on the soft palate and gland enlargements in 
cervical region well marked. Again put on the mer- 
curial treatment, and this time by nightly rubbing in \ 
dram of ung. hydrarg. mixt. under the arms and knees 
alternately. The mucous patches were touched with 
the solid arg. nit. After about a fortnight the patches 
being quite healed, the gums scarcely, if at all, affect- 
ed, the right submaxillary gland began to inflame, 
and in spite of local applications, of immediate cessa- 
tion of the mercurial, and the administration of iodine 
and cod-liver oil, it went steadily on to suppuration. 
The patient here passed from observation. Some three 
years after he was reported as having several epileptic 
seizures, finally dying of cerebral ramolissement. 

Remarks. — The early prominent feature in this case 
is the gangrene occurring in the initial lesion. Auspitz,* 



* Anatomie d. Syph. : Initial Sklerose. Von Prof. H. Auspitz u. Dr. 
Paul Unna. Vierteljahrschrift f. Derm. u. Syph, (1876), s. 161. 



SYPHILIS AND THE GENITOURINARY DISEASES. 99 

Unna,* Beisiadecki,f Verson, Kaposi, and others have 
shown that the induration of the initial lesion is depend- 
ent upon a dense infiltration of cells and development of 
fibrous tissue which interferes more or less with the 
vessels of nutrition. Complete obstruction occurring in 
certain cases, gangrene results as in the foregoing case, 
and is essentially different from the molecular gangrene 
of chancroid, which is the result of the destructive nature 
of the lesion per se. Hence the treatment by mercu- 
rials, which tends to produce fatty metamorphosis of the 
obstructive material in the initial lesion of syphilis, and 
thus relieve the cause of necrosis, is indicated ; while 
in gangrene or phagedenia occurring in the chancroid 
the mercurial influence would tend to hasten the de- 
structive action. 

The fact that the slough was confined to the indu- 
rated mass, and that healing went rapidly on under the 
mercurial treatment, is in confirmation of the foregoing 
view. 

The inability to bear a mercurial treatment may rea- 
sonably be attributed to the scrofulous diathesis, and 
this aggravated by every sort of dissipation and impru- 
dence. The father of this patient died of chronic phthi- 
sis, and this patient had had swellings of cervical glands 
without suppuration some years previous. The occur- 
rence of epilepsy, and subsequent death from brain dis- 
ease, (which was designated cerebral softening,) in a 
young man of twenty-four years, can safely be consid- 
ered a legitimate sequel of syphilis. It is reasonable to 
believe that, had the patient been able to bear a pro- 
longed and systematic course of treatment by mercu- 
rials, he would have, in all probability, escaped the 
trouble which caused the fatal issue. 

In the recent work of Hill and Cooper, of London 
(1881), prominent English authorities, the following 
statement occurs : " There is also p;ood foundation for 

o 

* Zur Anatomie der Syphil. : Initial Sklerose. Vierteljahrschrift f. 
Derm. u. Syph. (1378), s, 531. 

+ Archives of Acad. Sciences, 1S67. (Otis's Physiology, Pathology, 
and Treatment of Syphilis. New York: Putnam. 1SS1.) Vienna, 1S73. 
Vol. i., p. 53. 



IOO PRACTICAL CLINICAL LESSONS ON 

the belief that steady, prolonged mercurial treatment, 
although not an infallible means, is the only trustworthy 
one for preventing a return of the disease." 

Bumstead and Taylor, in their late work* (New 
York, 1879), g"° so f ar as t0 sa y tnat " we know that 
the great majority of cases (estimated as high as 95 
per cent) which have been thoroughly treated are 
absolutely cured, and are never followed by a relapse." 
It is not, then, easy to estimate the gravity of the misfor- 
tune to one who, having acquired syphilis, is unable to 
bear a systematic mercurial treatment. With judicious 
management such cases are fortunately rare. 

* Fourth Ed., 1879, P- 810. 



SYPHILIS AND THE GENITO-URINARY DISEASES. IOI 



LESSON XIII. 

Clinical case — Initial Lesion complicated with Herpes and Phimosis — Dif- 
ficulties in diagnosis — Treatment — Contagious character of secretions 
from all fractures of skin or mucous membrane during active stage of 
Syphilis — Falling of hair due to cell accumulations about hair bulbs — 
Polymorphous character of Syphilis in some cases — Absence of charac- 
teristic lesions in others. 

CASE VI. — Initial lesion, occurring upon herpes and com- 
plicated with phimosis. Followed by roseola, mucous patches, 
and alopecia.— H. T., merchant, 34, had suffered on fre- 
quent occasions during several years with herpes pre- 
putialis, the little watery vesicles of which would ap- 
pear sometimes independently of any venereal exposure, 
and again would follow such exposure within three 
or four days. In several instances the vesicles be- 
came pustules, and small ulcers were formed ; but 
through the use of the simple lead lotion recovery 
had always taken place within a few days, except 
in a single instance, when it was fully a fortnight in 
healing, and there was said to have been much swell- 
ing and hardness. His prepuce was redundant and 
habitually covered the glans penis, but was readily re- 
tracted and was kept scrupulously clean, as he had long 
previously found that inattention to this favored the 
production of the herpes. Occasional venereal connec- 
tions were indulged in, with great care taken to secure 
immunity from disease. The only person with whom 
connections had been had, for three months previous, 
was with one who was thought entirely above suspicion 
of having any venereal trouble. A fortnight previous, 
three or four days after last connection, a group of her- 
petic vesicles appeared. These were on the inner layer 
of the prepuce, at its attachment near the frenum, on 
the left side. They were treated as usual with the lead 
water and disappeared within a few days, with the 



102 PRACTICAL CLINICAL LESSONS ON 

exception of two points which pustulated, and finally, 
when about the size of a small split peppercorn, coa- 
lesced. Had much necessary walking to do, and the 
parts after about ten days became so swollen that the 
prepuce was retracted only with pain and difficulty. 
Still certain that the trouble was a simple herpes, aggra- 
vated by his exercise and by a rather debilitated gen- 
eral condition from overwork, he sought advice only as. 
to herpes. This was about four weeks subsequent to 
his last connection. 

Condition on presentation, June 10, 1878, as follows: 
In good general health, but somewhat debilitated from 
overwork. Penis somewhat turgid and reddened ; pre- 
puce redundant, covering glans. Orifice contracted, 
so that the glans could not be exposed. Pressure be- 
tween the fingers, just at the base of the glans on the 
left side, showed some slight condensation of the tis- 
sues and caused some pain, and oozing of slight muco- 
purulent fluid. Two inguinal glands about size of a 
marrowfat pea in left groin. No amount of argument 
would persuade the patient that his difficulty was likely 
to prove different from the attacks of herpes with which 
he was familiar, and he declined, almost indignantly the 
suggestion that an examination of his paramour should 
be made in order to aid in determining the exact nature 
of his difficulty. Absolute rest on the lounge or in bed and 
injections of weak lead and opium wash to thoroughly 
lave the preputial cavity was continued for the next 
two weeks. The attempts to retract the prepuce gave 
so much pain that it was no longer attempted. Under 
the rest and sedative treatment the soreness diminished, 
but an induration, which was appreciated in some de- 
gree on first examination, was now increased, and the 
two glands in the left groin, one above and the other 
below Poupart's ligament (and which had been stren- 
uously insisted on as the result of strain occurring a 
long time previous), were evidently increasing in size 
and were slightly tender on pressure ; besides this sev- 
eral smaller glands were now appreciated on the op- 
posite side. With these strong evidences of syphi- 
litic trouble, the patient was finally persuaded to sub- 



SYPHILIS AND THE GENITO-URINARY DISEASES. 103 

mit to a mercurial treatment, commencing with pil. 
proto-iodid. hyd. J grain, three times daily, and 15 
drops Wyeth's dialyzed iron in a glass of milk, while 
the same local applications were continued. On the third 
day pills every six hours. At the end of a week the 
tenderness of the local lesion was scarcely perceptible, 
and the swelling less prominent. Glands no longer 
sensitive on pressure. No effect of the mercurial seen 
in the mouth, but a slight intestinal irritation causing 
two or three fluid passages from the bowels, -J- grain of 
the watery extract of opium was added, and a dram of 
ung. hvd. mit. ordered to be rubbed alternately into 
each thigh every night. No further intestinal trouble. 
The preputial swelling and tenderness decreased so 
much within the next fortnight that the prepuce was 
retracted (though with some difficulty), discovering on 
its inner surface a superficial erosion about as large as 
a five-cent piece, set in a distinct and characteristic 
disc of indurated tissue. Slight tenderness of gums 
appearing, the ointment was suspended, and pills (J gr. 
protoiodid.) reduced to four, omitting the opium, which 
had caused slight constipation. 

July 5th (seven weeks after last connection), the ulcer 
had quite healed, but the induration remained promi- 
nent. The patient called attention to a bright rosy 
eruption which was distributed profusely over the 
body, a few spots on the face and palms. Glands in the 
cervical region distinctly enlarged ; size varying from 
a buckshot to a No. 4; one especial] v prominent on 
either side of the ligamentum nuchae. Left epitrochlean 
size of small pea; right, not discoverable. Mercurial 
well borne ; no tenderness of gums, but a slight red 
line was seen at the border of the gums of several teeth. 
Has had some soreness of throat. Examination shows 
right tonsil inflamed and somewhat swollen ; fauces 
deeply congested ; patient advised to leave off smoking. 
Ordered sat. sol. potass, chlorat. to be used as. a gargle 
and habitual wash for the mouth, teaspoonful to a tum- 
bler of water, three or four times a day. 

July 30. Has continued the medicine steadily. Rose- 
ola faded out in about two weeks leaving scarcely a trace ; 



104 PRACTICAL CLINICAL LESSONS ON 

soreness of throat also passed off leaving the parts still 
congested, but free from tenderness ; smokes occasion- 
ally ; does not think it affects his throat ; gums not 
affected. 

August 10. Calls, complaining of return of throat 
trouble ; otherwise doing well. Examination shows a 
small patch of superficial ulceration on the right side of 
the soft palate, bordered with a narrow gray line ; also a 
small crack in the mucous membrane at the left angle of 
the mouth. Explain the importance of such lesions: 
viz., that mucous patches or any cracks in mucous mem- 
brane, of whatever character, during the first year of 
syphilis at least, give rise to a contagious secretion, and 
when brought in contact with an abrasion in a healthy 
person, on the lips or elsewhere, will communicate 
syphilis. 

Touch the ulcerations with solid nit. arg. very 
lightly, just to whiten, and recommend that this be 
repeated daily until their complete healing. Also as 
gums are not at all red or tender, increase pills again to 
four daily and prohibit smoking entirely, as the effect of 
tobacco always is to aggravate and prolong syphilitic 
difficulties of the mouth and throat. Patient complains 
of his hair falling out; wishes to know if this is due also 
to his disease. State that it certainly is, but that under 
faithful pursuance of his treatment this as well as the 
other difficulties will in all probability be but temporary. 
A stimulating wash was given for the hair. 

The subsequent history of this patient presented no 
salient features. His acute throat trouble passed off in 
a few days, but the faucial mucous membrane continued 
congested for many months. The alopecia, which in 
some cases extends to entire loss of hair, eyebrows, 
etc., in this instance was never sufficient to attract 
attention. The induration on the site of the initial 
lesion gradually became smaller, but was not entirely 
gone for quite a year from the date of its appear- 
ance, although the treatment was kept steadily up, 
scarcely missing a dose, giving as much as the patient 
would bear without producing tenderness or red- 
ness of the gums, or irritation of the bowels ; this was 



SYPHILIS AND THE GENITO-URINARY DISEASES. 105 

from three to six pills of the proto-iodide during each 
twenty-four hours for a little more than a year. At this 
time all evidences of cell accumulation at the site of the 
initial lesion had entirely disappeared. The glands in 
the groins were still slightly enlarged, but those in the 
cervical and left epitrochlean regions had quite gone. 
Was very anxious for consent to marry, but advised to 
a twelve months' course of what is familiarly known as 
the mixed treatment — Mist, biniodid. hydrarg. contain- 
ing Jj- biniodid. and 8 grs. potass, iodid. thrice daily. 
This was taken faithfully, and borne without trouble 
of any sort. Six months after this, he not having seen 
any evidences of his former trouble for over a year, and 
as the inguinal glands, although slightly enlarged, were 
not greater than many who have never had syphilis, 
consent was given to his marriage — about two years 
and a half from date of acquirement of the disease. A 
short time since he called, having been happily married 
for over two years, to state that he had had not the 
slightest return of his old trouble, nor had his wife con- 
tracted any disease ; his only trouble was that, as yet, 
he had had no children. 

Remarks. — The occurrence of an initial lesion on the 
site of a herpes preputialis, as shown in the foregoing 
case, is not infrequent. On the contrary, there is no 
more favoring condition for the acquirement of syphilis 
than a predisposition to herpes. A slightly irritant 
leucorrhceal discharge is often sufficient to determine 
an attack, and the bland and unirritating nature of the 
disease germ of syphilis does not interfere with the 
natural course of the herpes. It should never be lost 
si°:ht of that no lesion occurring: after an illicit vene- 
real contact can be safely pronounced free from dan- 
ger of having been the point of entrance of a syphilitic 
disease germ until after the longest period which has 
been known to elapse between inoculation and the ap- 
pearance of the initial lesion, and this is never less 
than forty days. 

Second point of especial moment is the prompt effect 
of the mercurial treatment in reducing the tenderness 
and swelling, not alone of the initial lesion but of the 



106 PRACTICAL CLINICAL LESSONS ON 

adjacent glands, adding- proof to the position that 
mercury acts on the newly proliferated syphilitic cell 
material which distends and disturbs the tissues, in- 
ducing a fatty metamorphosis, (through which alone 
living material can be eliminated from the organism,) 
and aids also in deciding between opposing authorities, 
some of whom* claim that mercury should be withheld 
as a rule until the manifestation of constitutional syph- 
ilis appears ; while others f claim that the treatment by 
mercury should be commenced as soon as the initial 
lesion can be recognized as such. Certainly, if mer- 
cury acts in curing syphilis through any property it 
is known to possess, it is by its power to hasten tissue 
metamorphosis or fatty degeneration ; and if it has 
this value in the cell accumulations of the so-called 
secondary manifestations, it cannot be denied in the 
accumulations constituting the initial lesion, which has 
been shown by such authorities as Cohn, Beisiadecki, 
and others, to be virtually identical in composition and 
nature with them. Hence we are prepared to agree 
intelligently with those who begin the treatment of 
syphilis at the earliest moment of its recognition. 

The usual tolerance of mercurials, given in doses, and 
with the frequency sufficient to produce a mild and 
curative effect, is well shown in the foregoing case. 

It will be observed that the papular eruption, which 
often occurs about the third or fourth month of syphi- 
lis, was apparently absent. Its equivalent was, however, 
recognized, in the mucous patches in the mouth, and in 
the alopecia, which is found by microscopic examination 
to result from accumulation of cells about the hair 
bulbs, similar to those forming the papule on the skin 
in other cases. The polymorphous character of syphilis 
in the acute stage is well seen in this case, but it will 
be found that no two cases are alike in the number, 
locality, or degree of development of their manifesta- 
tions, and that cases may even be met which pass 
through the different stages of the disease without pre- 



* Bumstead and Taylor ("Venereal Diseases." Philadelphia: 1879). 
\ Hill and Cooper (London : 1881). 



SYPHILIS AND THE GENITO-URINARY DISEASES. 10/ 

senting a single characteristic lesion of the skin or 
mucous membrane ; the only evidence of syphilis being 
confined to gland enlargements (often escaping- obser- 
vation), and the subsequent occurrence of well marked 
sequelae of syphilis. 



108 PRACTICAL CLINICAL LESSONS ON 



LESSON XIV. 

Clinical case — Initial Lesion on the lip — Simulating Epithelioma; also the 
mucous patch— Dark color of papular eruption on a quadroon — Rose- 
ola passing off in 48 hours — Malposition of Epitrochlean Gland — Ease 
with which enlarged glands sometimes escape discovery — Subsequent 
papular eruption — Occurrence of Iritis due to same cell accumula- 
tion as produces the papule — Treatment for all lesions in the active 
stage of Syphilis the same — New troubles not an evidence of relapse, 
but incidents en route — Treatment of Iritis — Persistence of the papular 
eruption Characteristics — Recurrence after disappearance, and in same 
spots formerly occupied — Continued recurrences — Significance of this — 
Question of marriage a difficult one in such cases — State of papular 
eruptions significant of changes previously effected in the skin where 
papules occupy spots of previous eruption, and suggestive of non-con- 
tagious stage. 

Case VII. Initial lesion. Mucoid form, simulating a 
mucous patch. . Large papulo-pustular eruption. Iritis — 
Acquired from woman with mucous patches and a mili- 
ary papular eruption. A. W., chemist, 38, presented 
December, 1878, for an opinion as to the nature of a 
small superficial ulcer just inside the lower lip, near 
the right labial commisure. Patient had suffered oc- 
casionally with " cold sores" about the lips, and thought 
the trouble of that nature, until a medical friend sug- 
gested that it might be a commencing epithelial can- 
cer, the result of excessive smoking, and ought to be 
shown to a surgeon. Two surgeons had examined 
the sore, one of whom was confident that it was an 
epithelioma ; the other thought it doubtful, and sug- 
gested syphilis, and advised him to get another opin- 
ion. The lesion was nearly circular, and about as 
large as would be covered by the top of an ordinary- 
lead pencil; its surface was slightly elevated, florid, 
granular, and covered with a grayish pellicle. The 
tissues on which it was situated were quite hard to the 
touch, for perhaps a quarter of an inch surrounding. 
But for this induration it could not have been distin- 
guished from a typical mucous patch. Two slightly 



SYPHILIS AND THE GENITO-URINARY DISEASES. IO9 

enlarged lymphatic glands lying over the parotid were 
found ; none at any other point. The patient denied ever 
having had syphilis, or any sexual connection for more 
than a year, but admitted kissing a female domestic in 
his family on several occasions. No other evidence of 
trouble was found. After much argument the gentle- 
man at last consented to send the domestic for examina- 
tion. She proved to be a very handsome quadroon, 
very simple, and evidently unaware of having any 
venereal disease. She admitted that she had had some 
sore-throat and a profuse leucorrhcea, but denied ever 
having had sexual intercourse ; denied also having 
had any sores of any sort, except an occasional " can- 
ker' in the mouth. Examination revealed an exten- 
sive superficial irregular ulceration of the soft palate, 
bordered with the diphtheric deposit characteristic of 
the syphilitic mucous patch. She had also well-marked 
gland enlargements in all the usual localities, and a 
miliary papular eruption over the body. The papules 
were about the size of a large pin's head, in groups of 
6 to 8 or 10, an inch or more apart, and appeared on the 
light coppery skin of the quadroon as of a deep purple 
color. At first claiming that she had always had these 
dark points, she finally confessed that they had appeared 
only two or three months previous, and also that she 
had had a single illicit connection some months before, 
but stoutly denied all knowledge of having had any 
local disease. 

With this positive knowledge of syphilis and the 
strong circumstantial evidence which it afforded, there 
was but little room to doubt that the suspected epithe- 
lioma of the lip was an initial lesion of syphilis, acquired 
through contact with a mucous patch ; the secretion 
of which, as well as all the secretions throughout the 
active stages of syphilis, being well known to possess 
the contagious property equally with the open initial 
lesion of syphilis. 

Mr. W. was satisfied to commence a systematic mer- 
curial course, as advised. Pil. duplex (hyd. mass. 2 grs. ; 
ferri exsic 1 gr.) was taken steadily for about a month, 
at the rate of three per day, without any trouble of any 



110 PRACTICAL CLINICAL LESSONS ON 

sort, except slight tendency to fluid passages from the 
bowels, which was readily corrected by a little pare- 
goric. Having been instructed to watch carefully for 
any eruption, he called within a few days, with a 
slight mottling of the skin on back and abdomen, so 
indistinct, however, it was quite uncertain whether this 
was anything more than the natural spottiness which is 
not uncommon in cool weather. Gland enlargements in 
the cervical region were now distinctly made out ; none 
in the inguinal or epitrochlean. 

On the following day, by careful inspection, looking 
across the back, and also the abdomen, against a strong 
light, a pale eruption, slightly elevated in places, made 
it quite certain that it was the roseola, initiating the 
constitutional stage of syphilis. It passed off com- 
pletely, however, very soon, for 48 hours afterwards it 
could not be certainly detected at any point. 

It is worthy of note here, that another careful exam- 
ination for an enlarged epitrochlean gland resulted in 
its discovery fully the size of a marrowfat pea, and 
situated at least three inches above the epitrochlean space, 
between the borders of the biceps and triceps muscles. 
The knowledge that such malposition is not very un- 
common, and that quite large glands, having sometimes 
very loose attachments, will slip under the borders of 
muscle or fasciae in such a way as to elude any but the 
most careful and persistent search, may occasionally be 
serviceable. 

During the next few weeks nothing noteworthy, 
except congestion of the faucial mucous membrane, 
which at times was quite swollen and sensitive, but tem- 
porarily relieved by chlorate of potash gargle, and occa- 
sional spraying with a 40-gr. solution of argent, nit. 
Finally, two or three small superficial ulcers occurred 
on the tonsils, and at about the same time some redness 
and pain in the left eye, which had been quite weak for 
a day or two. Examination showed some conjuncti- 
vitis, the iris slightly discolored and duller than the 
opposite, and on closing and opening the lids quickly, 
with aid of a thumb on either eye, it was seen that 
the iris of the left eye was nearly immovable ; and, as 



SYPHILIS AND THE GENITO-URINARY DISEASES. Ill 

if it were not sufficient to have discovered this well- 
marked example of a mild type of syphilitic iritis, it 
was also found that a scanty eruption of papules, some 
as large as silver three-cent piece, had developed on 
the back, arms and legs ; not the least irritation an- 
nounced their presence ; they were rosy in color, 
slightly elevated, and quite insensitive to touch. The 
patient was very despondent from this combination of 
ills until assured that the trouble with the throat, the 
eye, and the integument, were simply evidences of the 
same papular eruption, modified by locality ; an accu- 
mulation of cells which had caused a disturbance by 
their presence, chiefly mechanical, and which, with the 
aid of the treatment, would, in all probability, pass off 
in a short time without leaving any permanent trace. 
That they were not evidences that the treatment thus 
far pursued was unsuitable or inefficient ; but that, in 
the necessity of avoiding damage to healthy struc- 
tures, the process of destroying and eliminating this 
imperfect cell material, accumulated in the mucous 
membrane of the throat, in the iris, and in the skin, was 
a comparatively slow but a sure one. That nothing 
else was necessary but to go steadily on with the mer- 
curial, in just that amount and frequency as could be 
borne without damage to the sound material and tis- 
sues in which they were imbedded. That these new 
troubles were not the evidence of a relapse or coming 
anew under .the syphilitic influence, as manifested in 
the apparently arrested and transient roseola. They 
were simply incidents, adverse currents, or shoals, if you 
will, on the onward voyage towards recovery ; that 
while many made this voyage with scarcely a ripple 
of discomfort from beginning to end, others met with 
varying obstructions and delays ; but all eventually 
passed through, and few comparatively, if well guided 
to its termination, found themselves much the worse for 
the experience. The distillation of a couple of drops of 
a solution of atropine (2 grains to the ounce of distilled 
water) into the affected eye, had the almost immediate 
effect of demonstrating that slight adhesions of the iris 
to the anterior capsule of the lens had taken place, 



112 PRACTICAL CLINICAL LESSONS ON 

irregularity in border of the iris becoming visible. 
This, however, soon gave way under a few repetitions 
of the atropine, at intervals of three or four hours, which 
also relieved the pain. The attack proved a very slight 
one, for no other treatment became necessary ; and after 
continuing the dilatation by atropine for a couple of 
weeks, and simply avoiding a strong light, all evidences 
of the trouble had disappeared. The initial lesion and 
the induration, never extensive, had quite disappeared. 
The papular eruption remained, and although the mer- 
curial was well borne, and an occasional sense of tender- 
ness of the gums announced the limit of endurance of the 
remedy. At the end of another month it had not entirely 
lost its salience, although it had quite lost its reddish 
color and assumed a deep coppery hue. Occasional 
papules showed an exfoliation of the epidermis at their 
base, which condition, resulting from the interference 
with nutrition through the cell accumulation causing 
the papule, constitutes a valuable point in diagnosis. 
With a steady continuance of the treatment, however, 
the spots gradually disappeared, having continued (from 
the date of their appearance until they could no longer 
be detected) fully three months. Nothing then occurred 
to interrupt the favorable course of the trouble in this 
case — throat trouble having gradually faded out: the 
gland enlargements almost gone. After nearly a year, 
however, the treatment in the period having been faith- 
fully pursued as initiated, small scaling papules ap- 
peared. These were flat, slightly thickened spots, rather 
than papules, about the size of a lead pencil top, with 
their silvery border of epidermal scales, when discov- 
ered, and, had it not been for previous history, could 
not have been distinguished from spots of simple pso- 
riasis. There had been on each hand only a very few 
spots of the original papular eruption, say five or six, 
and had caused the chief discomfort of the patient at 
one time, as they constituted the only evidence of syphi- 
lis to a casual observer. On this account they had 
received quite a little local treatment by mild mercurial 
unguents, and with apparent success, as they passed 
off at least a month before those on the body. The 



SYPHILIS AND THE GENITOURINARY DISEASES. II3 

statement (which the patient made quite confidently) 
that these spots had returned in the exact places occupied 
by the former eruption was noted. Similar carefully- 
observed cases which had been met, where a return of 
such an eruption over three years (in one instance) after 
the original papular eruption, and in the same places, 
seemed to indicate that the later eruption might belong 
rather to the sequelae of syphilis than to the evidences 
of the active contagious disease. And the treatment 
was changed from the simple mercurial to the combina- 
tion of mercury, with the iodid. of potass. (Mist, binio- 
did. hydrarg., see page 259.) A few weeks of this treat- 
ment, added to ung. hydrarg. nit. and vaseline, equal 
parts, locally, caused entire disappearance of this, and 
after three months further treatment with the misturas 
biniodid. (3 three times a da)'), it was suspended from 
accidental causes for nearly a month, when the spots 
returned, and apparently on the exact sites of the former 
spots. Treatment resumed, with the addition of a fumi- 
gation thrice weekly, thirty grains of resublimed calo- 
mel, (this preparation, on account of its less irritant 
property, being preferred), and moderate inspiration of 
the vapor advised, if it could be borne without pro- 
ducing cough. 

Again, within a few weeks, the spots disappeared, and, 
as the gums became slightly tender, the fumigation was 
omitted, continuing the "Misturas Biniodid." alone. The 
patient then went on living very regularly, and taking 
his medicine as ordered, and with scrupulous care, as 
he was under engagement of marriage formed just pre- 
vious to his inoculation, and desirous of hastening his 
recovery in every possible way. After six months of 
this treatment, in order to test his condition, he omitted 
his medicines and the spots returned in less than a fort- 
night. This was the only evidence of the syphilitic dia- 
thesis now remaining, for the throat had long since 
ceased to show any unusual engorgement, and the 
glands in all localities, while still distinguishable, were 
no longer characteristic. Another six months, making 
fully two years from the date of his inoculation, and the 
patient presented very worried, stating that while he 



114 PRACTICAL CLINICAL LESSONS ON 

was quite well in every other respect, and had no trouble 
of any sort when he took his medicine, as soon as he left 
off treatment, the scaly spots would return on his hands, 
and always in the same places. He was very anxious 
for some definite time to be set when it would be safe 
for him to marry. It became necessary to advise this 
patient that, in the present state of knowledge in regard 
to such a relapsing eruption following syphilis, it was 
uncertain whether or not any contagious element was. 
still associated with it ; that the active stage of syphi- 
lis was one of steady progression, while the sequelae 
were prone to relapses. That the repeated recurrence 
of the scaling spots on the same sites were significant 
rather of organic change in the vessels of nutrition in 
the affected integument than of an infecting material 
free in the blood ; but inasmuch as there was not suffi- 
cient available experience to decide this point positively 
it would be necessary for him to postpone his marriage 
indefinitely, and go on with his treatment until the ces- 
sation of it, as tested from time to time, was not followed 
by a recurrence of the trouble. Then, according to 
best authorities, he should wait a full year, which, if 
passed without evidence of syphilitic trouble, he might 
venture to consider himself well, and marry. This pa- 
tient is now two and one-half years from the date of 
inoculation, and has passed nearly three months with- 
out treatment or any return of trouble. 

Remarks. — The occurrence of the syphilitic initial 
lesion on the lip is not very rare. In the foregoing case 
the contagion was undoubtedly direct, but this is the 
point, more than any other, where the initial lesion may 
be looked for as a result of mediate contagion, viz., con- 
tact as of the lips with any articles which have been in 
use by persons who have mucous patches on the lips or 
in the mouth or fauces. Hence, when syphilis is sus- 
pected, and the site of the initial lesion in doubt, this re- 
gion should be examined with great care. The presence 
of enlarged lymphatic glands in the vicinity is of great 
value in clearing up a diagnosis, for these are rarely, if 
ever, absent in syphilis beyond the third or fourth week 
after inoculation, and may often be found at a much 



SYPHILIS AND THE GENITO-URINARY DISEASES. 115 

earlier period. (For explanation of manner in which 
mucoid form of initial lesion is formed see page 108.) 

Various modifications of the papular eruption of 
syphilis will be met, no two cases presenting exactly 
the same arrangement, locality, or degree of develop- 
ment. The miliary variety where the papules are about 
the size of a pin's head, sharply acuminated, and often 
into a little serous accumulation or a scale at*the sum- 
mit, and thickly and irregularly distributed, or in groups 
(like that described in the female associated in the fore- 
going case), or arranged in circles or figures of 8. Again, 
the papules may be large and flat in groups, or thickly 
and generally distributed, or sparsely (as in the above 
case of A. W.), but to a certain extent always symmetri- 
cal on either side of the median line of the body — a fact 
which characterizes the early papular eruption as con- 
tra-distinguished from that sometimes occurring in 
groups and unsymmetrically at a later period, as towards 
the end of the first year of infection, or subsequently. 
Papules may be associated with pustules ; may all be 
more or less pustular ; may even begin apparently as 
pustules ; and thus a great variety of eruptions of a papu- 
lar or papulo-pustular character may be met in the early 
period, say from the third to the sixth month after in- 
fection. The presence of such eruptions, whether we 
designate them after authorities by the size or shape 
of the papules, or according to their real or supposed 
resemblance to simple diseases of the skin, as the lich- 
enoid, the lenticular, the scaling papular (syph. psoria- 
sis), the annular (syph. lepra), or the acneiform, the 
variola form, the impetigo form, or the ecthyma form, 
we must nevertheless bear constantly in mind the fact 
that one and all, if of syphilitic origin, are the result 
of the localized accumulation of cell material, hastily 
generated through the syphilitic influence ; taking the 
different forms through constitutional idiosyncrasies or 
dyscrasias, and, according to the late microscopic re- 
searches of Kohn, Auspitz, Virchow, Neuman, Baum- 
ler, always beginning in a papillae cutis, * and that 

*See Otis on "Physiology, Pathology, and Treatment of Syphilis:" 
Putnams, 1881, p. 33. 



Il6 PRACTICAL CLINICAL LESSONS ON 

the treatment for all is the same, varied in degree only, 
to suit the constitutional peculiarities of each case. 
It is also proper to state that no eruption can be pro- 
nounced syphilitic from its appearance alone, but that, 
in order to warrant such opinion, gland enlargements 
must also be present more or less pronounced in the 
various localities where the superficial lymphatic glands 
are located, as in the cervical, inguinal, and epitrochlear 
regions. It will also be seldom that other evidences 
are not also present, one or more, such as congestion of 
the throat, ulceration of tonsils, mucous patches in the 
mouth, or between the toes, or at the anus. It is then 
evident that the form, color, size, or locality of an erup- 
tion is not the test as to its nature, but it must always 
be traced to a probable syphilitic origin before it is 
warrantable to pursue a systematic mercurial course. 
That, so traced, every variety of eruption of a papu- 
lar, pustular, or vesicular character, or any combination 
of these forms occurring between the second and 
seventh months after a syphilitic inoculation may be 
said to have its cause in a localized cell accumulation 
beginning in a papilas cutis. For the elimination of this, 
a gentle persistent mercurial treatment is indicated not 
only as the result of clinical experience, but from the 
fact that it is " the remedy, par excellence, for inducing the 
fatty metamorphosis : through which alone the cell accumu- 
lations occurring during the acute stage of syphilis can be re- 
moved!' 

Papular eruptions, and their variations, in the early 
stage are sometimes slow in reaching their full develop- 
ment, varying usually several days and sometimes as 
many weeks, but there are apparently no relapses, the 
new accessions appearing always at new points. The 
so-called relapses coming on soon after the disappear- 
ance of the first crop of papules, coming as they usually 
do in groups, would seem to be due to the setting free 
of infectious material stored in temporarily obstructed 
lymphatic glands. In other cases where the eruption 
recurs at same points (as in present case,) this would 
seem to be due to changes in the skin from previous 
damage, and may ultimately have to be classed among 



SYPHILIS AND THE GENITOURINARY DISEASES. II J 

the sequelce rather than among the manifestations of the 
active period of syphilis, or that in which a contagious 
element is still present in the blood and in the secre- 
tions of all lesions. Further observations on this point 
will be presented when considering the later periods of 
the disease. 



Il8 PRACTICAL CLINICAL LESSONS ON 






LESSON XV. 

Clinical case — Hunterian Chancre — Treatment by excision — Mode of 
operation — Ulcerating papular eruption — Mucous patches and papules 
— Treatment — Unfavorable influence of tobacco and alcohol — Good 
effect of Syphilis on habits of patient — Treatment well borne — Length 
of time required to keep it up — Time when immunity from danger of 
communicating the disease arrives — Length of probationary period 
before marriage — Causes and conditions which occasion pustulation. 
and ulceration in the papular eruptions of Syphilis. 

Case VIII. Initial lesion. Papulo- pustular eruption, 
mucous patches, and papules, etc. — G. M., aged 18; bar- 
tender ; presented with a characteristic specimen of the 
so-called Hunterian chancre on the superior aspect of 
a redundant prepuce. The open lesion was fully three- 
fourths of an inch in length by one-third of an inch in 
breadth, imbedded in a cartilaginous matrix about a 
quarter of an inch broader and longer, and moveable on 
the inner reflexion of the prepuce. This had been sev- 
eral months in coming to these dimensions — not quite 
certain as to time ; appearing first as a slight chafe and 
gradually increasing in size and density under a variety 
of local applications — caustic and sedative. No inter- 
nal treatment had been resorted to. Glands in groin 
and cervical regions enlarged and hard. No history 
of previous veneral disease. General health not very 
good, but no particular pain or trouble except, latterly, 
occasional headaches, sometimes in the day but chiefly 
at night. Examination shows a large, deep red papu- 
lar eruption rather thickly scattered on the back and 
breast chiefly, but on the thighs pustules were present 
about the size of a split pea, scabbed and surrounded 
by a slight inflammatory areola, while on the legs, es- 
pecially near the ankles, were several superficial ulcer- 
ations covered with brown scabs as large as a dime, 
looking very angry and sensitive. Also several points 
of superficial ulceration between the toes, the sur- 
rounding surface presenting a whitish sodden appear- 



SYPHILIS AND THE GENITOURINARY DISEASES. II9 

ance, the secretions very offensive (mucous patches). 
Besides these were several moist papules, quite ele- 
vated, and open pustules on the scrotum (mucous pa- 
pules and tubercles, simple and ulcerated). The throat 
was deeply congested, but neither this nor the mouth 
presented any localized lesion. 

Diagnosis : Syphilis, in the fourth or fifth month. 

Treatment : As the initial lesion was easily movable 
on the underlying cellular tissue, its enucleation was de- 
cided upon. After the parts had been thoroughly 
cleansed and bathed with a one to sixty solution of car- 
bolic acid, the indurated mass was tightly encircled by 
a small silver wire, and the tissues beneath it transfixed 
with a sharp pointed bistoury, cutting out first one half 
and then the other, thus removing the entire mass. 
Half-a-dozen turns of continuous suture of black thread 
closed the wound satisfactorily, and a simple wet bo- 
rated cotton dressing was applied. The mucous patches 
and tubercles were swept lightly over with the solid 
argenti nitras, and the patient was put on the usual 
mild mercurial treatment with an extra tonic. Thus, 
(Mass. Hyd. 2 grs., Ferri Exsic 1 gr., and pil. quin. bi- 
sulph. 2 grs.) one of each thrice daily, and in addition 
at the same time, a teaspoonful of a solution (made up 
fresh daily) of the sulphide of calcium (2 grs. to 2 1 of 
water). Rest in bed or on a lounge until healing of the 
wound of operation ; simple but nutritious diet. On the 
third day, when the stitches were removed, healing was 
found to be complete. Under the local and internal treat- 
ment above indicated, touching the mucous patches and 
papular daily with the arg. nit., this, with the abstinence 
from tobacco to which the patient was addicted in all 
forms, resulted in prompt improvement, and in a short 
time the open lesions had entirely healed and returned 
to their original papular condition, and the sulphide of 
calcium was dropped. Through the indifference and 
want of sense in the patient the continuation of the mer- 
curial and tonic treatment was very irregular, and its 
effect was, moreover, much depreciated by occasional 
excesses in alcoholic stimulants and tobacco. While 
there was no return of ulceration in the papules, an 



120 PRACTICAL CLINICAL LESSONS ON 

ulceration involving both tonsils occurred, requiring 
local treatment (application of acid nit. fort, at first, then 
solid argent, nit.) for several weeks, and finally healing, 
leaving the whole pharynx congested, and at times 
quite sensitive. A saturated watery solution of the chlo- 
rate of potassa had been in daily use as a gargle and 
mouth-wash from the commencement of the mercurial 
course (as is usual in such cases), and was continued 
with occasional applications of a strong solution of 
tannin and glycerine, when the sensitiveness of the 
gums became manifest. The mercurial treatment was 
kept up more or less regularly, as originally com- 
menced, for about a year, only twice or thrice result- 
ing in any perceptible effect on the gums. The papu- 
lar eruption passed off the body, quite losing the sali- 
ence within two or three months ; but on the thighs, 
wherever a pustulation had occurred, a faint coppery 
stain was discernible at the year's end, and on the 
legs, where the ulceration was most marked, the stain 
was at that time of a deep coppery hue. The throat was 
no longer habitually congested, but still it was more 
easily affected by changes of weather than formerly, 
and the occasional necessity for his gargle was recog- 
nized. The general health of patient had not suffered 
during this long period of medication. He had become 
steadier in his ways, and had been for some time per- 
fectly regular in his treatment. The gland enlargements 
at all points were greatly decreased, but still readily dis- 
cernible. Of the initial lesion there was not a trace. 
Even the line of union of the cut surfaces was scarcely 
to be distinguished from the natural creases or wrinkles 
in this locality, and there was absolutely no more evi- 
dence of loss of tissue than if a simple foreign body had 
been removed. The patient now wishing to change 
his residence to a distant part of the country, desired 
specific instructions as to the length of time he still 
required to continue treatment, and what changes, if 
any, were to be made. 

He was informed that the present treatment, or its 
equivalent, should be pursued for still another year, 
always in such degree as not to affect the general health 



SYPHILIS AND THE GENITOURINARY DISEASES. 121 

unfavorably. Alternating- it from time to time with the 
iodide of potassium (5 or 6 grs., three times a day), or 
taking that drug in combination with it — (Mist. Binio- 
did. Hydrarg.) He desired still further to inquire as to 
whether or not he was still capable of communicating 
the disease through ordinary contact, or otherwise, and, 
if so, when he would probably be free from such danger. 

In response to this he was informed that, although 
he had no open lesion, the contagious element of the 
disease was doubtless still in his system, and that the 
complete disappearance of the material evidences of the 
disease, which included gland enlargements, at all points, 
would be necessary before the incapacity to commu- 
nicate the disease could be reasonably claimed. That 
this, in a case like his, where early treatment had been 
neglected, and he had suffered from some of the severer 
lesions of the disease, immunity from danger of communi- 
cating syphilis could not confidently be expected in less than 
from two to three years from the date of its acquirement. 

That while lesions of syphilis certainly recognized as 
containing a contagious element, such as the true mu- 
cous patch, papule, or tubercle, were rarely, if ever seen, 
after the first year, but if the contagious element was 
still in the system, it might escape through an ordinary 
abrasion, or wound, or sore, of any description, and, if 
brought in contact with a fracture of skin or mucous 
membrane on a healthy person, it would communicate 
syphilis. Thus sexual contact was not without dan- 
ger of communicating syphilis in such cases, even when 
no recognized syphilitic lesion was present at any 
point. 

Again, lastly, he desired to be informed as to whether 
or not he would, as a conscientious and upright man, 
be justified in looking forward to marriage within the 
next five years. 

This question, virtually identical with the previous 
one, yet embracing the assumption of a responsibility 
which, if assumed prematurely or in error, might inflict 
irreparable 'evil on a future wife and offspring, could 
only be fully answered after the probationary period of a 
year subsequent to the cessation of the treatment. 



122 PRACTICAL CLINICAL LESSONS ON 

Provisionally, it might be stated that, after the pur- 
suance of a judicious, thorough, and well-borne mercu- 
rial course for at least one and a half to two years, and as 
long after (up to three years) as necessary to secure the 
complete disappearance of all gland enlargements due to 
syphilis aud all other evidences of the activity of the disease 
then if, for the full period of one more year, on care- 
ful scrutiny no evidence of the disease was manifest, 
consent to marriage would be justifiable as far as the 
question of communication of syphilis was concerned. 
But every person who has once suffered from syphilis, 
no matter in how light or how transient a form, is liable 
to suffer from trouble in various forms, known as the 
Sequelce of Syphilis. The earlier and more thorough the 
treatment the less the liability to these troubles. They 
might be very slight and pass off without recognition 
even, or be so grave as to threaten life. Such troubles, 
usually spoken of as Tertiary Syphilitic lesions, con- 
stituted a purely personal matter in every case, wholly 
lacking the contagious element. They are not a neces- 
sary part of syphilis, and, when occurring and recog- 
nized early, they are eminently amenable to treatment. 
As before stated, those cases of syphilis early, thor- 
oughly, and wisely treated, during the active period 
of the disease, escape as the rule. Yet every one 
once the subject of syphilis should never forget the 
possibility of such accident, and, whenever suffering 
from any serious or unusual difficulty, should always 
communicate the fact to the medical attendant in charge 
of the case. 

Remarks. — The foregoing case presents a good exam- 
ple of the causes and conditions which determine pustu- 
lation and ulceration in the papular eruptions of syphilis. 

1. The debilitated condition of the patient favoring 
the suppurative process. 

2. The character of his business requiring many hours 
daily in a standing position, producing additional ten- 
dency to congestion in the papules of the lower extremi- 
ties, and this increasing the suppurative action, result- 
ing in the ulcers about the legs and ankles ; papules also 
becoming mucous patches and ulcers in moist places. 



SYPHILIS AND THE GENITOURINARY DISEASES. 1 23 

Consideration of the causes which may affect any pre- 
senting eruption of syphilis from condition, locality, and 
business, etc., will suggest judicious modifications in the 
hygienic as well as the medicinal treatment, and make 
us hesitate in classifying eruptions of identical origin in 
a manner tending to obscure the real causes of differ- 
ence in appearance and amenability to treatment. 



124 PRACTICAL CLINICAL LESSONS ON 



LESSON XVI. 






Length of time required for complete cure of Syphilis variable : gentle, 
steady influence of mercury from one and a half to three years — Popu- 
lar prejudice against mercury not well grounded — Testimony of all 
authorities in its favor — Destructive lesions of Syphilis belong to the 
late stage — Treatment not addressed chiefly to the accidents of the 
active stage, but to the prevention of so-called Tertiary accidents — The 
Sequelae of Syphilis — Unwarranted responsibility taken by those who 
claim safety after a brief period of treatment — Light form of early 
Syphilis no guarantee against grave late lesions — M. Fournier's views 
— Prolonged and judicious administration of mercury essential in every 
case of Syphilis — Exceptions where treatment is not well borne very 
few — Security against late troubles to be effected in no other way. 

General remarks. — The length of time usually required 
for the complete cure of syphilis will vary in different 
individuals from one and a half to three years, and dur- 
ing all this time the steady, gentle influence of the mer- 
curial in form, dose, and mode of administration as pre- 
viously stated (page 119) is required until all abnormal 
cell-accumulations dependent upon the syphilitic influ- 
ence have disappeared. When after a year and a half to 
two years all external evidences of the disease have passed 
away, and the lymphatic glands can no longer be felt, or have 
returned to the condition in which they were found pre- 
vious to the constitutional stage of the disease, the treat- 
ment may be discontinued, but not before, unless there is 
some idiosyncrasy in the patient which contra-indicates its 
use. If the patients are faithful, sensible, and obedient, 
in by far the largest majority of cases, they will pass 
through the trouble easily and happily to a complete 
cure. A great weight of experience in the plan of 
treatment which I have indicated (including that of the 
most distinguished authorities in Europe and America), 
assures us of the truth of this, and the patients do not 
suffer from the long-continued treatment in any appre- 
ciable way, and that in consequence of it they have the 
greatest and the only security of escape from the so- 
called tertiary, or late lesions — the sequelae of syphilis. 



SYPHILIS AND THE GENITO-URINARY DISEASES, 1 25 

I am quite aware that there is a great popular preju- 
dice against the use of mercury in syphilis, and this has 
arisen in great measure from the abuse of the drug in 
earlier times, but it has been kept up and intensified by 
quacks and the ignorant and the unworthy of our pro- 
fession, who, from causes and motives natural to these 
classes, refuse to accept the testimony of the learned 
and experienced authorities, who are now in complete 
accord in this matter, in every part of the world. With- 
out a show of evidence, or experience, entitled to respect, 
they deny the necessity of the mercurial treatment, and 
make the pretence, that syphilis may be as efficiently, and 
more safely, managed without it. They point to cases 
thus treated, apparently well of the disease, and claim 
them, as evidences of the truth of their statements. The 
very important fact, that syphilis, in its acute period, is 
a self-limited disease, and will pass away with any sort 
of treatment, or without treatment, is not made appar- 
ent. This is the fact, and while we claim and know, 
that a judicious mercurial treatment, will hasten the cure 
of the active lesions and stages of syphilis, it is not on 
this account, that the treatment is considered essential. 
It is because, more than any other known remedy, it 
prevents the sequelae of syphilis — the so-called tertiary 
and quarternary lesions — which result in destruction of 
important tissues and organs, vessels and bones. These 
accide?its do not occur in the early or acute stages of syphilis. 
After the apparent disappearance of syphilis, in a few 
months, or a year or so, there comes a deceitful period 
of perfect health, perhaps. The disease is perhaps 
cured ; but in two, or three, or ten, or twenty years after, 
new trouble may arise, no longer contagious, as in the 
past syphilis, but destructive. It is this, that causes the 
really important damage. Deformity, disability of body 
or brain, or both, and, finally, in some cases, death. It 
is to avoid the danger, present in every case of syphilis, 
of such results, that the persistent and judicious use of 
mercury during the acute period of the disease is most 
important, and is, as we fully believe and know, abso- 
lutely essential. We do not urge the administration of 
mercurials, without a due consideration of the respon- 



126 PRACTICAL CLINICAL LESSONS ON 

sibility we take in so doing, without a knowledge of all 
it has ever done, that is objectionable, or ever may do. 
It is because, without a systematic, judicious mercu- 
rial course, the patient who has once been a subject of 
syphilis, in no matter how light a form, or how slight or 
short-lived the manifestation, is in jeopardy every hour, 
and that nothing but a course of simple mercurial treat- 
ment, continued systematically for at least a year, can 
afford any reliable security. This is the experience of 
all in our profession who have any title to a respectful 
hearing, on account of wisdom and experience, and in 
the present state of our knowledge of this matter it is 
sufficient to warrant you in insisting upon the necessity 
of such a course of treatment in every case of syphilis 
which in the future may present to you for care and 
treatment.* 

Do not understand me to say that every case shall be 
treated in the same manner, as to the size of the dose or 
the mode of administration, and without regard to the 
physical condition and circumstances. A judicious fol- 
lowing of the plan insisted on is necessary, i.e., such an 
amount and such a mode of administration as may be 
borne without disturbing the digestive apparatus, or 
materially interfering with the processes of nutrition. 
As a rule, if the medicine is judiciously administered, 
the patient will not only not be disturbed, but he will 
improve in both these respects. How much a more 
regular and exemplary mode of life, which a proper 
management of syphilis necessitates, has to do with the 
improved condition, I am not able exactly to state, but 
it is nevertheless a fact, that most young men are in 

* The distinguished French syphilographer, M. Fournier, says on this 
point: " Experience teaches us that syphilis, originally mild, may reveal 
itself sooner or later in serious symptoms, if it has not been submitted, 
like the more malignant forms, to a prolonged and severe treatment. 
One has seen, more than once, syphilis of this kind, negligently treated 
by reason of its apparent benignity, become, later, singularly dangerous 
in marriage in the double possibility of contagion and heredity. ... It 
is to-day proved, that the initial benignity of syphilis does not constitute 
in any degree an absolute guarantee for the future. Such syphilis which 
begins well, is not, for that reason, unexposed to a bad end." ("Syphilis 
and Marriage," by M. Alfred Fournier. London Ed. 1881, pp. Ill, 112.) 



SYPHILIS AND THE GENITOURINARY DISEASES. 12/ 

better health, after a judicious course of specific treat- 
ment for syphilis, than before its acquirement. 

1 do not wish to be understood that no other medi- 
cines are necessary, or advisable, in any case of active 
syphilis. There are idiosyncrasies that must be re- 
spected — cases that will not bear the ordinary amount 
of mercurial without trouble of some sort These are 
fortunately rare ; but when they present, you must use 
your ingenuity, so to select the particular form, and com- 
bine your most excellent remedy, that it may be borne. 
You may alternate it with the iodide of potassium, 
which is also an agent of much value in bringing about 
fatty degeneration of living tissue, or you may, if you 
can do better, rely upon this drug in combination with 
other means and measures which are known to favor 
fatty degeneration and elimination. 

You are likely to meet with cases that will try your 
temper and courage: that will call into fullest requisi- 
tion all your knowledge and your experience and your 
judgment, and, not least, all your common sense, and 
yet fail to obtain such a toleration of the mercurial as 
will enable you to prevent the occurrence of the sequelae 
of syphilis. These cases will, however, I am glad to 
say to you, be rare exceptions, and you may have the 
assurance of the rule, that such a plan of treatment as 
I have sketched out for you will be well borne, and will 
not alone aid you, in carrying your patient with com- 
parative equanimity and comfort, through the acute 
stages of this disease, but, what is of infinitely greater 
importance, you will give him, the greatest possible se- 
curity, against an occurrence of the sequela or manifes- 
tations of so-called chronic or tertiary syphilis. 



128 PRACTICAL CLINICAL LESSONS ON 



LESSON XVII. 

Resume showing that the contagious property of syphilis is not an in- 
dependent virus pervading all tissues, but is confined to the white blood, 
or tissue-building cells, and that the only peculiarity of such cells is 
a contagious influence which is not distinguishable by microscopical 
examination. That its effect is to induce hasty proliferation of cell 
material, and that the result of this is not primarily destructive, but 
causes disturbance through mechanical interference with processes of 
nutrition. The property of contagion, inherent in normal cell develop- 
ment; all troubles occurring after the contagious period of syphilis^ 

» which clinical observation has shown to be limited — necessarily con- 
sidered as sequela. Mr. Hutchinson's views on this point; the views of 
Mr. Henry Lee and Mr. Lane. The tubercular eruption the first sequel 
of syphilis. Its characteristics and behavior. Syphilitic ecthyma; 
syphilitic rupia; no specific element in their composition. The lepra 
and psoriasis of syphilis not distinguishable from the simple forms ex- 
cept through effects of treatment, all caused by interference with natu- 
ral functions of tissues. Evidences of this interference confined to the 
lymphatic channels. This view supported by Rindfleisch, also by 
effects of treatment, all alike requiring mercury and the iodide of potas- 
sium. Proposal to substitute the term Period of Lymphatic Obstruc- 
tion for the old terms, Tertiary and Quarternary Syphilis. Reasons 
for claiming that this syphilitic obstruction is due to damage to lymph 
channels during the active period of syphiliSo 



THE SEQUELS OF SYPHILIS. 

Syn,: Chronic or Late Syphilis, Tertiary and Quater- 
nary Syphilis. — In following the natural history of syph- 
ilis, as portrayed in the preceding pages, it will be 
seen, that, wherever the syphilitic influence is recognized 
at a given point, culminating in a well-marked mani- 
festation of syphilis, this, on microscopic examination, 
has been found to differ from the healthy surrounding 
structures, only by an excessive local proliferation and 
accumulation of cells, in no way distinguishable from 
normal germinal cells. It will also be seen that this local 
proliferation and accumulation, is favored by anatom- 
ical conditions, in localities long recognized, clinically, 
as the favorite seat of such manifestations. 

The active period of syphilis, thus marked by exces- 
sive localized cell proliferation, was shown to be equally 
characterized by the contagious property attaching to 



SYPHILIS AND THE GENITO-URINARY DISEASES. 1 29 

cells thus generated. Inoculation of the blood, and of 
the secretion of all open lesions, during the active period 
of syphilis, has been found capable of communicating 
syphilis promptly to healthy persons. 

The physiological secretions — milk, saliva, mucous, 
urine, perspiration, tears, and the spermatic fluid — have 
not been proven to be agents of syphilitic infection. 
Where apparently so, in many cases, syphilitic lesions of 
the mouth or breast have been found, to account for the 
seeming inoculability of the saliva or of the milk. Re- 
peated experiments have been made by inoculation of 
the spermatic fluid of a person proven to be in the active 
stage of syphilis, upon healthy persons, with absolutely 
negative results.* In this we find confirmation of our 
position, that the contagious property of syphilis is not 
an entity, an independent virus, pervading all the tissues 
and fluids of the organism, but that it is confined to the 
white blood or tissue-building cells. In this view of 
the matter we readily see how the physiological secre- 
tions above mentioned, which do not contain formative 
cells, are found also to be free from the contagious 
property of syphilis. 

Thus far, the only distinguishing feature which has 
been recognized, between normal embryonal cells, and 
cells which make up the accumulations characteristic of 
the active stage of syphilis, is the possession, by the lat- 
ter, of the contagious property. In other words, a con- 
tagium : the power of setting up in other cells, through 
simple contact, the same disposition to rapid prolifera- 
tion, which the so-called syphilitic cells are known to 
possess. The direct result of this hasty proliferation, as 
far as we have yet been able to discover, is not a de- 
structive action. It is, simply and only, what we should 
naturally expect from hastily generated normal material, 
in excess of the necessities of growth and repair. In 
representative, uncomplicated cases, it remains for a 
time, obstructing the tissues by its presence, and then 
through purely normal processes, (often of necessity set 

*Dr. Mireur, of Marseilles. Annales de Dermatologie et de Syphilo- 
graphie, No. 6, tome viii. 1877= 



I30 PRACTICAL CLINICAL LESSONS ON 

into operation by crowding- of the newly-formed cells, 
prolonged pressure, and consequent innutrition, and also, 
from general causes), it undergoes fatty degeneration, 
and is in this way finally eliminated from the affected 
organism.* 

Baumler virtually supports this view f when he says 
of the active stage of syphilis, " If there are only a few 
local deposits, the elimination of the virus may be so 
much in excess of its production that the organism is 
gradually freed from it. This takes place in the majority 
of cases, and, at the expiration of eighteen months or two 
years, the infection is entirely exhausted!' 

Mr. Hutchinson, of London, in speaking of the con- 
tagious property which attaches to the emasculated 
white blood cell, which we call pus, says, " All living 
pus is contagious. ... I mean," he further says, 
"that all pus cells possess the power of setting up, 
when transferred to another home, if that home be a 
suitable one, a kind of inflammatory action similar to 
that from whence they themselves had originated." % 
This, we know, results in the almost immediate death 
of cells in localities so contaminated. In the case of 
the germinal cells, contaminated by contact with the 
syphilitic cells, however, this results in a hasty genesis 
of cells, a too rapid production, which prevents their 
highest development ; they fall by the way, are heaped 
up, undergo fatty degeneration, and are, or may be, 
eliminated. Nor is it alone in diseased cells that a con- 
tagious property is claimed to reside. We have dis- 
tinguished authority for saying that, in the normal de- 
velopment of epithelial structures, the property of 
contagion is an essential feature. § If this be true, it at 
once becomes evident that the contagious property is 
not of necessity a virus ; and it must, I think, be sug- 
gested, in this view of the matter, as equally evident, 

* A fatty metamorphosis, entirely like that which occurs pathologically, 
occurs in the normal condition of the organism. Wagner, p. 305. 

f P. 247 of Ziemssen's Cyclopaedia, Am. ed., vol. iii. 

\ London Lancet, September 18, 1875, P- 4°9- 

§ Text-Book of Pathological Histology. Rindfleisch. Am. ed.. 1871, 
p. 100, § 83. 



SYPHILIS AND THE GENITO-URINARY DISEASES. I3I 

that the so-called virus of syphilis is simply the manifest- 
ation of a property or personal influence, inherent in 
all cells, whether healthy or degraded, and which is as 
subtle and intangible, as incapable of material dem- 
onstration, as the influence which one mind exerts 
over another. Is it not then possible, that the mischief 
which syphilis does, is rather the result of an interfer- 
ence with the normal processes, through hasty develop- 
ment, brought about by this influence, than of the action 
of a specific virus ? 

In any event this contagious property of syphilis 
ceases with the active period of the disease. After 
this has passed, the secretions of open lesions, and the 
blood, no longer contaminate. It may also be said, that, 
in by far the greater number of subjects of syphilis, 
(and more especially those who have been systemati- 
cally and judiciously treated), they remain free from any 
farther sign of the disease. If this be so, then we may 
legitimately claim, that, at the termination of the active 
period of syphilis, just described, all subsequent troubles 
must be looked upon as sequelce, and not as a stage of 
syphilis, any more than we should look upon dropsy 
as a stage of scarlet fever, or stricture as a stage of 
gonorrhoea. Mr. Hutchinson, who is recognized as 
one of the most advanced of the English authorities on 
syphilis, says : " What are called tertiary symptoms, do 
not constitute a necessary stage, and are rather to be 
regarded in the light of sequelce, which may or may 
not show themselves." * Mr. Henry Lee (also a valued 
authority), in his Hunterian Lectures, delivered at the 
Royal College of Surgeons of England in 1875, pre- 
sents the same view of so-called tertiary or late syphilis, 
thus : " The pathological changes in this class, occasion- 
ally, according to Mr. Lane's view, present themselves 
in patients, who have passed through the primary and 
secondary stages of syphilis, but in whom the venereal 
poison no longer exists, and therefore cannot be tra?zs- 
mitted." 

This is, I know, quite at variance with the usual 

* London Lancet, p. 83, January 17, 1874. 



132 PRACTICAL CLINICAL LESSONS ON 

teaching in this matter. The accidents following upon 
the active period of syphilis are usually represented, 
not as sequelae, but as the direct result of the syphi- 
litic virus, which had never been completely elimi- 
nated, but had remained in the system in a latent state. 
Authorities are quite agreed, however, in regard to 
the clinical fact, that, after a varying interval, of from 
one to forty or fifty years from the acquirement of 
syphilis, a new variety of lesions appears in certain 
cases. 

These are often characteristic, although widely dif- 
ferent in locality, appearance, and results. Occurring 
only in a small proportion of the subjects of active sj T ph- 
ilis, they are thus shown, not to constitute an essential 
stage of the disease, but the accident of it. Thus the 
so- called tubercular eruption, like the papular eruption of 
acute syphilis, in some respects, is often mistaken for 
it, but differing, in that 

ist, it never* occurs in less than six months, and 
rarely under a year, from the acquirement of the initial 
lesion ; 

2d, it is not symmetrical and generally distributed, 
but in patches, or groups, or single tubercles, 

* I am aware that ulcerative lesions occur, though rarely, at the usual 
period for the papular eruption, that are accepted by some authorities as 
belonging to the later stages of the disease. I think, however, in all 
such cases, that the possible behavior of a papule or a lesion, resulting 
from the peculiar condition of the subject, will be sufficient to explain 
the nature of the accident without referring it to the so-called " tertiary 
stage;" or, if not, it will be found that the patient has had a previous at- 
tack of syphilis at a period sufficiently remote to account legitimately for 
the appearance of a tertiary lesion. The tubercle or its equivalent, viz., 
an accumulation of so-called gummy or germinal material, which is the 
result of a necessary previous stage, and lacks the contagious element, 
is the first of the accidents of the so-called tertiary stage — the sequel 
of syphilis. Notwithstanding that M. Cornil, in his recent excellent work 
on syphilis (p. 204), states that, " In the tubercles and gummata of the 
skin are seen the latest and deepest manifestations of cutaneous syphilis," 
yet he also states (p. 215) that "the very first symptoms of syphilis 
may be deep-generalized pustular or ulcerating eruptions," identical with 
those coming on after a period of many years (the seqttelce), '"' following 
immediately after the chancre." — Cornil on Syphilis. Am. ed., Phila., 
1882. I do not hesitate to claim that such cases, wherecritically analyzed, 
will be found to be as rare, as where, in nature, fruit has the precedence 
of the blossom. — F. N. O. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 1 33 

3d, of deeper color, it is also more elevated — more 
juicy in appearance, 

4th, while frequently ulcerating (and often extensively), 
it not unfrequently passes off without ulceration, and yet 
leaving well-marked cicatricial depressions on its site. 
This latter is the chief diagnostic point, independent of 
history or other associated lesion, of the tubercular 
eruption of syphilis. In other cases, under apparently 
the same conditions, an eruption, sero-pustular in charac- 
ter, may occur, the eruptive points varying from three 
to six or more millimetres in diameter, often sparsely 
scattered over the entire body, which soon become cov- 
ered with thick yellow laminated incrustations, and 
these, when removed, discover only superficial loss of 
integument. This is known as the Syphilitic Ecthyma. 
And again, in still other individuals, one or many red 
spots may appear, which soon vesiculate and be- 
come covered with a dark sienna-colored scab, which 
accumulates in layers, and increasing in size, may 
reach even an inch or more in diameter, upon the re- 
moval of which sharply cut loss of tissue will be seen, 
not seldom involving the entire thickness of the integu- 
ment. This is termed by authors the Syphilitic Rupia. 
Examination of all these lesions fails to discover any 
specific material or element in their composition. The 
microscope shows chiefly serum, lymph and pus cells, 
blood and epithelial debris. A depreciated condition 
of the general system, is always the precursor of such 
symptoms, especially marked in the rupetic variety. 
And yet again, eruptions may occur presenting appear- 
ances similar to simple lepra, or psoriasis, or eczema, 
oftentimes so nearly identical in appearance that only 
the test of treatment enables even the expert derma- 
tologist to decide as to whether the disease is of simple 
or of syphilitic origin. Underneath the integument 
tumors sometimes occur, varying in size from a pea to 
a pullet's egg, in the cellular tissue, or in the sub- 
stance of the muscular structures ; often painless, seldom 
suppurating, except when subjected to prolonged and 
habitual pressure, often disappearing spontaneously and 
readily responding to suitable treatment. Tumors in 



134 PRACTICAL CLINICAL LESSONS ON 

the bones, called syphilitic nodes, are also possible, oc- 
curring, like the previously described lesions of the cu- 
taneous, cellular, and muscular structures, from accu- 
mulation of the so-called gummy material, at any time 
after a year or more from the occurrence of acute 
syphilis, and up to the latest years of life ; painless or 
painful according as the periosteum is more or less 
rapidly distended or pressed upon by overlying tissues. 
Chiefly occurring on the anterior surface of the long 
bones, especially of the tibiae, and on the external tables 
of the skull, occasionally involving the internal table and 
the diploe, and in such case sometimes disappearing spon- 
taneously without involving the scalp, and without a 
trace of necrosis, but leaving distinct evidences of loss of 
bony substance through the influence of pressure by the 
material cause, the tumor. Similar tumors of bone may 
occur at any point throughout the bony system, pro- 
ducing disturbance by pressure on important structures. 
Tumors in the various organs of the body, occur 
apparently from similar causes, and in the same irregu- 
lar way in point of time, involving, in order of fre- 
quency, as follows: Testes, liver, kidneys, brain, lungs, 
heart, etc. In some cases walls of the blood-vessels are 
found infiltrated with the same material of which the tu 
mors of syphilitic origin are found to be composed, and 
become obstructed, as in the brain, often causing fatty 
degeneration of the structures to which they are dis- 
tributed. In some cases, cicatricial bands are found to 
develop in organs the subject of syphilitic tumors, and 
by contraction and consequent constriction, destroy the 
secreting structures, notably seen in the liver and 
testes of subjects suffering from the later effects of the 
syphilitic influence in these organs. It will thus be 
seen that the diseased conditions, enumerated as char- 
acteristic of chronic syphilis (the tertiary and quater- 
nary syphilis of Lancereaux and other authors), are 
essentially different from true or acute syphilis, in date 
of appearance, mode and locality of development, and 
in the entire absence of the contagious syphilitic ele- 
ment. Microscopic examinations have brought to 
light the very important and interesting fact, that all 



SYPHILIS AND THE GENITOURINARY DISEASES. 1 35 

the various sequelas of syphilis, are characterized by 
the presence of a peculiar material, which, from its 
physical properties, has received the name of " gummy 
material." This material has been proven, by repeated 
and exhaustive microscopical examinations, to be made 
up of gelatinous fluid, containing normal cells and 
nuclei, which do not differ in the least demonstrable de- 
gree, from the white blood cells and nuclei of a healthy 
person. Wagner, perhaps the most recent standard 
authority, says of this gummous material (which he 
terms syphiloma): " Microscopically syphiloma con- 
sists of cells, or nuclei, or both at the same time, so 
that sometimes the former, sometimes the latter, exceed 
in number. Young syphilomata, as well as the periph- 
eral parts of the older ones, contain for the most 
part only nuclei, or nuclei and isolated cells ; the older 
syphilomata, not yet very atrophic, consist for the 
most part only of cells, or of cells with few nuclei. 
The nuclei offer nothing characteristic. They are from 
0.01 to 0.02 mm., large, round or rounded, or somewhat 
angular, and contain for the most part a distinct nucle- 
olus. The cells resemble most uninucleate colorless 
blood corpuscles ; their size varies, however, some- 
times, between 0.0 1 and 0.03 mm,; some are even still 
larger." * Again Wagner (page 436) says : " The in- 
fluence of syphiloma, on the organism, depends upon 
the fact, that the affected portions of the membrane and 
parenchymata, are more or less incapable of function ; 
dependent partly on the deposit of cells, and especially 
of nuclei, upon compression or secondary atrophy of 
the gland cells, nerve fibres, ganglion cells," etc. 

Baumler, who fully adopts Wagner's views, says : 
" From the fact of the close resemblance of the cells 
which pervade the tissues, or occur in the form of 
young tissue growths, with the blood-corpuscles, it 
is evident that, however much, they (authors) may 
characterize syphilitic new formations, they wholly 
lack specific 7nicroscopic characters!'' He also says : 
" Tumors of this sort (gummy), varying in consistency, 

* Wagner's Manual of General Pathology, Am. ed., 1876, p. 435. 



136 PRACTICAL CLINICAL LESSONS ON 

may develop in any organ in consequence of syphilis; 
but their favorite seats are in the subcutaneous cellular 
tissue, the skin, in and upon the bones, the liver, the 
testicles, the brain, the kidneys, and, especially in chil- 
dren, the lungs. According to Wagner's description," 
he further says, " they present the appearance of a 
grayish-red, soft, homogeneous mass, either without 
fluid contents or else yielding a scanty juicy-like mucus. 
They may occur as infiltrations of microscopic size 
scattered throughout the parenchyma of an organ ; and 
even when they appear as sizable tumors, as large as a 
walnut or larger, they are not encysted nor sharply 
defined, but merge directly into the surrounding tis- 
sue/' " The effects of a gummy tumor," says Baumler, 
" may extend to a great distance in case it has caused 
contraction of the calibre of some vessel, especially 
of a blood-vessel, which is particularly liable to occur 
when the tumor has its seat in the adventitia of a 
vessel. Fatty degeneration and wide-spread processes 
of softening may be the consequences of a tumor in 
itself insignificant, as occasionally happens in the 
brain. When situated in the skin, in the subcutaneous 
cellular tissue, upon mucous membranes and superficial 
bones, the gumma often makes its way to the surface, 
since in these situations it is not uniformly enclosed on 
all sides, but is exposed to unequal pressure. The 
entire infiltration then ulcerates." M. Cornil still 
later says of the histology of the "gummata:" " All the 
pre-existing cellulo-vascular tissue is thus infiltrated 
and crowded with cells, the enormous quantity of which, 
strangles the normal tissue elements, and impairs the cir- 
culation." * It is reasonable to conclude, from the fore- 
going facts and views, that contraction of vessels, often 
plays an important part in causing the lesions of 
so-called tertiary syphilis : a purely mechanical matter 
quite independent of the influence of any virus. In 
passing, I desire also to call your attention to the 
statement of Baumler, " that gumma often, makes its way 

* "Cornil on Syphilis," Am. ed., Henry C. Lea's Son & Co., Phila., 
1883 ; p. 207. Ibid., at pp. 208 and 209, illustrations are given of the 
manner in which these cells obstruct and obliterate capillaries and veins. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 1 37 

to the surface." I hope to be able subsequently to 
show how this occurs — not making its way, but pro- 
gressing, by natural forces, in line of the natural physio- 
logical channels. 

Ricord claims that tertiary lesions are not inoculable, 
and cannot be transmitted by hereditary descent. 
Bumstead states, in his last edition, after reviewing 
this matter, " Hence we consider the blood and the 
secretions in tertiary syphilis innocuous." * " Diday 
performed inoculations with the blood of persons in the 
tertiary stage of syphilis, and invariably with a negative 
result. Von Barensprung states that from observation 
as well as experiment he is persuaded that so soon as 
the syphilis has passed into the destructive forms of its 
tertiary stage, it ceases to generate an inoculable vi- 
rus," and, says Baumler, " clinical observation seems to 
confirm this view, both in respect to direct contagion 
and with reference to the inheritance of the disease." f 

These authorities, together with Lee, Hutchinson, 
Lancereaux, and many others of our best clinical and 
scientific observers, thus agree, fully, on this very im- 
portant point. What then, is there to show that the 
so-called " period of gummy products" (Lancereaux) is 
not simply a period of sequelae, when they are found, 
practically, by competent observers, to be free from the 
contagious property, and when by scientific investi- 
gators it is shown that they are capable of producing, 
without a virus, all the lesions, without exception, which 
ever occur in the so-called tertiary or gummy stage of 
syphilis ? — producing them, too, simply by interference 
with function of vessels and organs, not improbably 
through pressure, occasioned by the presence of ab- 
normal, or excessive accumulations of material, which 
the most experienced and learned microscopists, cannot 
distinguish, from the normal elements of new forma- 
tions. 

If then we accept the lesions of the so-called tertiary 
stage (or the period of gummy products of Lancereaux) 

* Venereal Diseases, Bumstead and Taylor, p. 448. 
f Ziemssen's Cyclopaedia, Am. ed., iii. 57. 



138 PRACTICAL CLINICAL LESSONS ON 

as sequelae, where shall we look for the causes of the 
undue accumulations of normal germinal material, at 
every point in the human organism, which are known 
to occur as a sequence of syphilis ? Naturally, it appears 
to me, in interferences with the lymphatic channels, 
through which, according to Rindfleisch, the nutritive 
material exuded into the tissues, in excessof the neces- 
sities of growth and repair, is returned to the general 
circulation.* 

According to the same distinguished authority, f 
" Luxurious new formations, catarrhs, and surface 
secretions of all kinds, must be produced when the 
lymph conveyance is hindered, and," he further says, 
" we will find this position in pathology very frequently 
confirmed." One thing is now admitted by all recent 
accepted authorities, namely, that all the surface 
secretions and new formations of the tertiary or 
gummy period, all the infiltrations and tumors, all the 
peccant elements which produce the varied lesions in 
the skin, in the cellular tissue, in the bones, in the 
viscera ; by whatever name characterized, are but the 
various forms of infiltration or deposit of gummy 
material. If this is, as it would appear by the results 
of scientific investigation to be, nothing more nor less 
than normal germinal elements, thus retained at various 
points, then the only legitimate way of accounting 
for this retention, would appear to be through ob- 
structions, " hindrances to the lymph conveyance," 
which, Rindfleisch insists, is of itself sufficient, inde- 
pendently of any question of syphilis, to produce just 
such results as are known to occur in the so-called 
tertiary stage or period of gummy products. 

And yet another circumstance would favor this 
view : clinical experience has shown conclusively that 
whatever the form or locality or name of a lesion, 
whether in the skin as a scaling eruption, or as a tuber- 
cular eruption, or as a heaping up of gummy exudation 
in scabs, with or without ulceration, or as an ulcerative 

* Rindfleisch, Pathological History, Am. ed., 1871, p. 92. 
f Ibid., p. 93. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 1 39 

loss of tissue, or whether as a gummy tumor in the 
cellular tissue, in the bones, in the viscera, or in the 
brain and nervous system — one and the same treatment 
is adopted and found most efficacious and judicious 
for all, namely, the administration of mercury and the 
iodide of potassium. I have not heretofore objected to 
the term gummy period (so called only from the simi- 
larity of its products to the viscid material which it was 
believed to resemble), nor to the term tertiary, which 
is a purely arbitrary one ; but it appears to me that we 
may now venture to substitute for these the period of 
lymphatic obstmction, as more scientific, because ex- 
pressing- the localization of lymphatic elements, which is 
proven to occur, and as suggesting the lymphatic canal 
system as among the possible causes of that localization. 
It appears to me that, inasmuch as it has been shown 
that the lymphatic spaces and vessels are primarily and 
chiefly affected and obstructed, during the active stage 
of syphilis, it is not unreasonable to infer that damage 
might have occurred to those spaces and vessels, during 
the active period of syphilis, which, if properly investi- 
gated, would lead to the true explanation of the failure 
of that system, to return to the general circulation, the 
germinal material exuded or developed in the tissues, 
in excess of the necessities of growth and repair, such 
as is practically demonstrated to have occurred in the 
so-called tertiary or gummy period of syphilis. There 
are various known facts and analogies which afford 
strong presumptive and circumstantial evidence that 
this view is the correct one. Among these we have, 
first, the fact, generally recognized, that the more severe 
and prolonged the secondary or active stage of syphilis 
the more certain and severe are the so-called tertiary 
or gummous manifestations.* Second, the results of 
treatment show, that the difficulty is not simply an 
aggregation or infiltration of material, which, when 
removed, restores the patient permanently, but that the 
conditions for its reproduction remain, and relapses 
occur. 

* Hutchinson, London Lancet, January 31, 1874, p. 159. 



I40 ■ PRACTICAL CLINICAL LESSONS ON 

Thus the iodide of potassium, is recognized as capable 
of most rapidly removing the gummous material, and 
thus of relieving symptoms ; but mercury is found 
requisite to produce permanent immunity. The iodide 
of potassium, acts readily in removing recent new for- 
mations and cell accumulations, probably through the 
iodine it contains. The fucus vesiculosus, a remedy in 
use for obesity, and popularly known as " antifat," owes 
its virtues to the same ingredient. But mercury is 
known not only to hasten dissolution and elimination of 
fatty matters and new formations : it is, besides, the only 
agent with which we can expect to disintegrate more or 
less long-standing fibrous obstructions. 

In the gummy accumulations of so-called tertiary 
syphilis, we are obliged to infer that some condition 
remains, after the removal of this material, which 
predisposes to, or causes subsequent reaccumulation. 
What is more likely, than that such condition, consists 
in obstruction of lymphatic vessels, the office of which 
is to carry just such material as we find producing the 
difficulty? Vessels, too, that have been, more than any 
other structures, involved in recognized troubles during 
the active stage of the disease. More or less inflam- 
matory action, usually of a very low grade, is recog- 
nised at different superficial points in the lymphatic 
system during this period. The well-known tendency 
of all such action, is to the deposit of fibrous material — 
the very material through which cicatricial contractions 
of other tissues are brought about. Analogous, in a 
degree, are the conditions which result in stricture of 
the urethral canal, ten, twenty, or even forty years after 
the original inflammation : conditions which set in mo- 
tion a process which culminates, finally, in obstruction 
to the passage of urine. 

It has been claimed that much of the trouble, in 
so-called tertiary syphilis, may be the result of wide- 
spread fatty degeneration caused by obstruction of 
vessels. 

It is well known that fatty metamorphosis occurs 
more easily in some subjects than in others — that 
purulent degeneration is most readily set up in the 



SYPHILIS AND THE GENITO-URINARY DISEASES. 141 

debilitated and diseased. It is also claimed by Hutch- 
inson and others that the liability to, and severity of, the 
lesions of the so-called tertiary period of syphilis " is 
in proportion to the duration of the secondary stage." 

Hence we may conclude, that the varied degrees and 
forms of so-called tertiary manifestations, depend upon, 
first, the damage caused during the " duration of the 
secondary stage," and inferentially in consequence of 
it ; and, secondly, upon the condition of the individual 
affected, and this quite independently of any specific 
virus. 

Notwithstanding the variety in locality, physical 
characteristics, and date of appearance, the sequelae of 
syphilis practically call for the same remedial measures. 
Whether it be a superficial scaling or a tubercular erup- 
tion, an ulcerative lesion of the integument, an osseous 
swelling or a necrosis, a tumor in the cellular tissue or 
in the brain, or in any other organ or locality ; whether 
it be a painless hypertrophy of the tongue or of the testi- 
cle, no matter how slight in degree or how destructive, 
all the lesions of this period are most efficiently treated 
by some form of mercurial, combined with the iodide of 
potassium. It is only necessary to know that the lesion 
presenting, is a legitimate sequel of syphilis, to deter- 
mine the character of the remedy to be used. The form, 
the size, and the frequency of dose will be suggested by 
the circumstances of each case ; but the agents through 
which we may expect the most rapid removal of the 
so-called "gummous material," upon the presence of 
which we are warranted in believing that all the trouble 
depends, are mercury and the iodide of potassium. It 
is the liviug material, obstructing nutrition of parts, 
which, in every instance, produces the destruction of 
tissue, as well as disturbances of function, that charac- 
terize the sequelae of syphilis. This is the inevitable 
conclusion to which we are led, by the published results 
of examinations, made by the most accomplished patholo- 
gists of modern times. There is no disagreement in re- 
gard to the presence of the so-called "gumma" of syphilis 
in all such cases. Destruction from the influence of syph- 
ilis may occur at any point where lymphatic vessels are 



142 PRACTICAL CLINICAL LESSONS ON 

present — in other words, at any point to which nutritive 
material is carried ; not only to the skin, the cellular, 
muscular, bony, and even cartilaginous structures, but 
to every part of the brain and nervous system. It will 
also be found that the behavior of tissues and struc- 
tures, infiltrated with the so-called gummy material of 
syphilis, in all forms in which it presents a destructive 
result, shows nothing, either by inoculation or by any 
physical property, which proves it capable of acting 
otherwise than by the mechanical influence of its pres- 
ence, by interfering with function and cutting off nutri- 
tion, through diminishing the calibre of blood-vessels, 
or possibly effecting their entire obliteration. 

The measures, theoretically, most efficient in setting 
up a tissue metamorphosis in, and removing this gummy 
material, are those which, practically and clinically, are 
found most promptly serviceable in curing the late 
lesions of syphilis. In point of fact, it is so well under- 
stood that mercury and the iodide of potassium, when 
judiciously administered, have a specific influence in 
curing the sequelae of syphilis, of whatever form or 
degree, that whenever a case occurs in which the 
diagnosis is doubtful it is customary to test the charac- 
ter of the lesion in question, by use of these remedies : 
failure to relieve, constituting a positive evidence against 
the syphilitic origin of the trouble. 

The administration of mercury and the iodide of 
potassium, combined, is found most serviceable in the 
early syphilitic sequlas, as for instance, in the tubercular 
eruptions which may appear before the contagious 
syphilitic principle has been eliminated from the affect- 
ed organism, that is to say, within the first two or three 
years from the date of the acquirement of the disease. 

These remedies, combined as in the following formula, 
are usually well borne : 

5 Biniodide of mercury gr. iii. 

Iodide of potassium 3 iii-vi. 

Tr. of orange peel 

Syrup of orange peel aa 1 i. 

Aquae ad. § viii. 

M. 
Sig. — A teaspoonful, thrice daily, after meals. 



.SYPHILIS AND THE GENITOURINARY DISEASES. 143 

As the ordinary teaspoon holds somewhat more than 
a drachm, it will be found that the patient in the above 
prescription will get one sixteenth gr. of the biniodide, 
and about 4 to 8 grains of the iodide of potassium at a 
dose. 

The same may be judiciously used in every form, 
stage, and date of syphilitic sequelae. If, however, the 
lesion is one where destructive action is a prominent feat- 
ure, or the brain or nervous system is the seat of the 
affection, the iodide of potassium may be increased by 
the addition of a drop of the saturated solution, 

Iodide of potass 3 viii. 

Distilled water 3 viii. 

M. 

at every dose, in from a wineglass to a tumbler of milk 
or water (preferably the former), up to 60 or 80 drops, 
or until troublesome iodism results. The favorable 
effect of this treatment may be often seen within a 
few days, but occasionally no benefit will be observed 
until the dose of the iodide has reached a very high 
point, viz., a drachm at a dose, and in cases of cere- 
bral gummata this dose may require to be continued 
over a very long period — several months, or even 
longer. In the very largest majority of cases the 
foregoing plan may be successfully pursued, varying 
the amount of mercurial, or of the iodide, within the 
limits indicated, in proportion to the gravitv and urgency 
of the case. The mercurial reaches its limit of efficiency 
when the constitution becomes slightly affected by it, 
as indicated by softening or tenderness of the gums 
and teeth, and should, at that limit, always be stayed. 
Should the iodide of potassium fail of toleration, the 
iodide of sodium may be substituted and better borne 
in the same doses. If still iodism quickly result, as in- 
dicated by irritation of mucous membrane of the dis- 
gestive tract, the tincture of iodine may be adminis- 
tered in doses of 10 to 40 drops in a wineglass of 
starch as prepared for laundry use, or what in my 
experience has often been a most serviceable and 



144 PRACTICAL CLINICAL LESSONS ON 

agreeable substitute for the iodide of potassium and 
sodium, viz : 

^ Iodine (crystals) ; gr. xviii. 

Iodide of potassium 3 i-iii 

Water q. s. 

Stuart's syrup or plain molasses to § viii. 

M. 

Let stand 12 hours. 

Sig. From a dessert to a tablespoonful, three or four 
times a day, after meals. 

Cod-liver oil is always indicated in cases when any 
cachexia is present, from syphilitic influence, or debility 
from an} 7 other cause. The diet should be simple and 
nutritious, and adapted judiciously to the condition of 
the patient. Stimulants should be denied except in 
cases of especial urgency on account of habitual use and 
great debility — red wines may be permitted, at meals, in 
moderate quantity. 

The pursuance of the general plan just presented, 
covers all cases, as far as internal remedies are con- 
cerned. Mercurial fumigations may be, and often are, 
promptly serviceable, especially in the ulcerative le- 
sions, and may be substituted for the internal administra- 
tion of mercury. Twenty grains of resublimed calomel 
may be vaporized in a Lee's lamp, placed under a cane- 
bottom chair, and the patient covered in with a rubber 
cloak, or even an ordinary blanket, and this repeated 
three or four times a week — due care being used to pre- 
vent taking cold after the operation — and continued until 
the disappearance of the lesions, or the occurrence of 
the specific effect of the mercurial. 

In regard to local applications for the non-ulcerating 
forms of trouble, ointments containing a mercurial in- 
gredient, such as the ung. mas. hyd., the ung. hyd. 
nitratis, or ung. hyd. prascip. alb., or a combination of 
the oleate of mercury (a 6 per cent solution), with an 
equal quantity of cosmoline or vaseline, is often service- 
able, especially in the scaling and non-ulcerating tuber- 
cular eruptions. 

For local application to open ulcerations, or losses of 
tissue, through the influence of the so-called gummy in- 



SYPHILIS AND THE GENITO-URINARY DISEASES. 14$ 

filtration, especially when advancing, pointed, and pain- 
ful, the powdered iodoform is often promptly beneficial. 
In all forms of open lesion of syphilitic origin this drug 
appears to be especially potent in its sedative, antiseptic, 
and healing properties; perhaps it is the most so of any. 
Throughout the treatment of the sequelae of syphilis 
the effort to appreciate the causes of any presenting 
trouble — the influences local and constitutional which 
may tend to modify, or aggravate, or interfere in any 
way with the favorable progress of recovery should 
be unremitting, and not to rely upon or seek after some 
drug or prescription which is vaunted for the cure of 
syphilis. Judicious attention to the general health, and 
to the idiosyncrasies of patients, often brings success in 
cases which would otherwise result disastrously. Many 
subjects of syphilitic sequelae, suffer greatly from the 
apprehension of communicating the disease to others. 
They are entitled to the assurance that such troubles 
are not contagious, and are of purely personal interest 
after a lapse of four or five years from the occurrence 
of the initial lesion of syphilis, and this whether a sys- 
tematic course of treatment has been pursued in the in- 
terval or the patient has been quite neglected in this 
respect. It is quite true that many cases have been re- 
ported claiming communication of syphilis five, ten, and 
even twenty years after the acquirement of the disease, 
but a single well-observed, well-authenticated case, re- 
ported by a competent authority, has not yet come to 
my knowledge, nor have I ever known such an accident 
to occur after three years from the date of the initial 
lesion. 

CLINICAL CASES ILLUSTRATIVE OF THE VARIOUS 
SEQUELS OF SYPHILIS. 

Case I. W. W. ; 28, physician. In December, 1874, 
after repeated suspicious connections during many 
months, one day discovered a small sore on his penis. 
This was treated simply and only locally, and continu- 
ing in a sluggish way for a couple of months, when it 
was proved to be a true initial lesion of syphilis by the 



I46 PRACTICAL CLINICAL LESSONS ON 

appearance of a well-marked roseolous eruption and 
mucous patches in the throat. A systematic mercurial 
treatment was then initiated, bringing the system 
gently under its influence, and continuing at the point 
of easy toleration, occasionally pushing it up to sensi- 
tiveness of the gums or teeth. When this occurred the 
iodide of potassium was substituted until all evidences 
of the mercurialism had disappeared, and then the mer- 
curial was resumed, either in the form of pil. duplex 
(mass, hydrarg., 2 grs.; ferri exsic, 1 gr.) or pil. pro- 
to-iodid. hydrarg. (J- gr.), three times daily. Under this 
treatment, borne satisfactorily for eighteen months, 
no further manifestations of syphilis occurred. The 
glands in the groin and cervical regions, and also in the 
epitrochlear spaces, which were characteristically en- 
larged 2t the date of discovery of the roseola, had ap- 
parently become reduced more than one half in size. 
It was confidently asserted by the doctor that his 
glands were enlarged for years before the discovery of 
the initial lesion, and were now as small as he remem- 
bered ever to have seen them. In consequence of this 
statement, in connection with the entire absence of any 
congestion of the faucial mucous membrane or any ab- 
normal appearance at the site of the initial lesion or any 
evidence of syphilis at any other point, all treatment was 
suspended. After six months, during which there was 
no sign of trouble of any sort, local or general, atten- 
tion was called to a cluster of dark red papules (twenty 
to thirty), about the size of a small split pea, situated 
on the integument of the left temporal region. They 
were quite prominent, insensitive, and while firm to 
touch had a juicy, semi-transparent appearance at the 
centre. On examination another patch of similar erup- 
tions nearly as large as the hand was discovered under 
the left scapula. These clusters of apparent papules 
constituted a typical illustration of the simplest form of 
the tubercular syphilide, one of the most common and 
earliest of the sequelse of syphilis. Treatment by a 
combination of mercury and the iodide of potassium 
(mist, biniodid. hydrarg., No. , page ) was at once 
commenced, and continued steadily, the eruption for 



SYPHILIS AND THE GENITO-URINARY DISEASES. 147 

a time increasing in prominence. At two points alone 
slight ulceration occurred, and a scab about the size of 
a five-cent piece was formed. After about four weeks 
the tubercles began to decline, with slight desquamation, 
and finally to sink below the surface, so that by the 
third month of treatment the only remaining evi- 
dence was a cicatricial depression on the site of each 
tubercle; the intervening spaces between these points 
being of a faint coppery hue. Treatment discontinued, 
but, in a month, several tubercles had returned, and again 
disappeared under same treatment as before — mild mer- 
curial ointment (ung. hyd. nit. et vaseline, aa I ss) — 
applied localizator two months. Again, on remitting 
treatment, in a week or two, evidences of return of the 
trouble on the side of the forehead were visible ; several 
spots were simply reddened, while small scabs formed 
on others. The treatment was resumed, and re-enforced 
by fumigations with the re-sublimed calomel tri- weekly,. 
and this continued steadily for three months, when,, 
no evidence of the return of the trouble presenting, the 
cicatricial spots distinctly paler than the surrounding 
skin, and the coppery stain scarcely noticeable, the 
treatment was again discontinued. August, 1881, the 
doctor called with the statement that he was about to be 
married unless some important objection should be 
raised. The cicatricial depressions were still distinct in 
both localities and quite white, and no evidence of 
activity of the former trouble. Glands in the various 
localities were distinct, but not changed by time or treat- 
ment since the cessation of active medication, eighteen 
months after infection. 

Thus a period of five years had then elapsed since 
any sign of activity of the disease had been manifested, 
and it was concluded that there was no valid reason for 
postponing marriage, — always excepting the possibility 
of some future trouble of local character, but not suscep- 
tible of hereditary transmission. Now up to February, 
1883, he has had no further trouble; has a wife and 
child, now eight months old, perfectlv well. 

Remarks. — As recent painless enlargement and indura- 
tion of lymphatic glands (first, those directly connected 



I48 PRACTICAL CLINICAL LESSONS ON 

with the initial lesion of syphilis ; and second, groups 
of glands at characteristic points, such as the cervical 
and epitrochlear) are the most certain diagnostic signs 
of the presence of syphilis, in a given case, so their 
gradual subsidence is the most sure evidence of the effi- 
ciency of treatment, and their final and complete disap- 
pearance the most satisfactory proof of the complete 
cure of the disease. 

It is, however, necessary to mention that painless gland 
enlargements are present, in some persons, independent- 
ly of syphilis, or of any distinct scrofulous antecedents 
or evidences of this or any other dyscrasia. Hence it 
becomes important to note the condition, in this respect 
of any person, presenting with known or suspected 
initial lesion of syphilis, not only for the diagnostic 
value attaching to recent painless gland enlargements, 
but as an aid in determining the proper duration of con- 
stitutional treatment. When the glands are in nor- 
mal condition at the time of inoculation of syphilis — i.e., 
not susceptible of recognition by the touch — a continua- 
tion of the treatment is necessary until their restoration 
to such condition. On the other hand, when apprecia- 
ble gland enlargements, are present before the system 
is invaded by the syphilitic influence, there will be no 
such guide for the cessation of treatment, and a much 
longer period will be required, before the patient can be 
assured of the propriety of discontinuing anti-syphilitic 
remedial measures. 

The administration of mercury by fumigation, as in 
the foregoing case, while not suitable for general sys- 
tematic treatment, is an excellent adjunct in certain 
cases. The necessity of a prolonged feeble mercurial 
influence is best met by its judicious internal adminis- 
tration, but in cases where this is not well borne, it may 
be supplemented by two or three fumigations a week — 
steadily, if practicable, or at intervals, when it appears 
desirable to produce the constitutional evidences of the 
mercurial influence. It is especially adapted to cases 
where eruptive and ulcerative troubles are present. The 
method of application is exceedingly simple. An ordi- 
nary tin basin set upon a couple of bricks, high enough 



SYPHILIS AND THE GENITO-URINARY DISEASES. 1 49 

to admit a small alcohol lamp to be placed under the 
basin. From fifteen to thirty grains of pure calomel (re- 
sublimed to carry off the free hydrochloric acid, which 
is very irritating to the respiratory apparatus) is placed 
in the basin over the lamp. This under a cane-bottomed 
or open-worked chair. The patient sits on this naked, 
and is then enveloped closely in an ordinary blanket — 
the lamp is lighted, and in the course of from ten to 
twenty minutes the calomel is vaporized, and deposited 
to a greater or less extent on the surface of the body. 
Still wrapped in the blanket, or slipping on a flannel 
night-dress, the patient gets at once into bed, and re- 
mains through the night. During the fumigation the 
vapor may be inhaled from time to time to advantage, 
especially if there are open lesions of the mouth or 
throat, or if a prompt mercurial effect is desired. If 
an irritative cough results, inhalation should be very 
limited, or suspended entirely. Where it is available, 
the fumigation lamp invented by Mr. Henry Lee of 
London, and in general use under the name of Lee's 
lamp, is preferable. In this a small amount of water is 
evaporated with the calomel. An ample water-proof 
garment in place of the blanket is also an improvement, 
but the results are fully much the same as with the 
simpler apparatus. There is no more clanger of taking 
cold after a mercurial bath or fumigation than after a 
simple warm bath, but it is desirable to secure a tem- 
perature in the room of about yo° F., and to have the 
patient clad habitually in flannels, light or heavy accord- 
ing to the season, throughout the period during which 
the baths are administered. When the mercurial fumi- 
gation is relied upon alone, and the patient is robust, it 
may be used nightly, using ten to sixteen grains, and 
continued for months without producing the apparent 
constitutional effects. If, however, signs of the mercu- 
rial influence appear in the mouth and breath, the fumi- 
gations should be promptly suspended. The incon- 
veniences attendant on this mode of treatment are such, 
that except it is manifestly the only way the mercurial 
can be efficiently introduced, the treatment by innunc- 



150 PRACTICAL CLINICAL LESSONS ON 

tion, or through internal remedies will be found greatly 
preferable. 

Case II. June ioth, 1874, N. L., 46, naval officer, pre- 
sented with a general and quite profuse, large, ham- 
colored, papular eruption, slightly scaling at borders, 
of some papules, chiefly on body and legs and arms, 
none on face. Mucous patches in the mouth ; well-marked 
gland enlargements in the cervical region, viz. along 
the posterior border of the sterno-cleido-mastoid muscle 
and of the trapezius, also in the epitrochlear and in the 
inguinal regions. On further examination, an indurated 
lump, the size of a pea, was found in the tissues of the 
prepuce on the left side. This was said to have come 
with a small sore some six months previously. Had con- 
sulted several surgeons, who thought his sore a simple 
one. It finally healed, after several weeks' continuance, 
through simple applications alone, but left a hard kernel 
on its site. No more attention was paid to the matter 
until the appearance of the eruption, some three weeks 
previously, when he was suffering from a supposed 
malarial attack. Having now some suspicions that his 
trouble was syphilitic, and not then desirous of confiding 
in the medical officer of his ship, he waited without 
treatment until his arrival in port. The case was one 
of undoubted syphilis in full bloom, and was at once put 
upon a systematic mercurial treatment. This was car- 
ried on now under the care of another surgeon — a most 
accomplished medical man — for about a year. During 
this time several consultations were held. The eruption, 
and all other external lesions, passed off satisfactorily. 
The chief difficulty experienced was a failure to produce 
the constitutional effect of mercury by the ordinary 
means. Three at first, then four, five, and even six pit. 
duplex (each 2 grs. mass, hydrarg. and 1 of exsic- 
cated sulph. of iron), were given daily, without appar- 
ent effect either on the gums or on the digestive appara- 
tus. Patient's general health excellent. Small doses 
of calomel (^ gr. every two hours) were given then in 
addition until gums responded, and at the same time a 
bilious diarrhoea set in and continued for several days. 
When this and the other evidences of mercurial action. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 151 

had completely disappeared, the patient resumed the 
mercurial in the form of pil. proto-iodid. hydrarg., 
three J-gr. pills, three times a day. The treatment 
was pursued steadily, for about three months, making 
about twenty months since the acquirement of the 
disease, and over a year of full and systematic treat- 
ment. This course was remarkably well borne, in every 
respect, and the patient was in excellent general health 
and spirits. There was now no external evidence of 
syphilis, and the glands in the various regions were no 
longer characteristically enlarged. Leaving home for 
a three months' cruise, the patient returned presenting 
a thickly studded tubercular patch about the size of his 
hand, under the left scapula : tubercles size of a grape- 
seed, and of a pale purplish-red color — with neither itch- 
ing nor tenderness to touch. Another group, chiefly of 
large tubercles, covered with brown serous scabs,ranging 
in size from a pea to a five-cent piece, arranged in a horse- 
shoe form four or five inches in diameter, appeared on the 
left thigh ; while several small tubercles were scattered 
irregularly over the buttocks, — thus presenting a well- 
marked specimen of the so-called tubercular syphilide 
in its several characteristic forms: 1st. The simple tu- 
bercular under the scapula, in an irregular patch, with 
each tubercle distinct, and of pale purplish hue, with no 
tendency to ulceration or exudation of serum ; this kind 
disappearing slowly by absorption of the material com- 
posing the tubercle, and leaving a distinct depressed 
cicatrix to mark the site of each. 2d. The tubercles 
coalescing and extending by a superficial ulceration, 
exuding serum and forming brownish scabs with a ten- 
dency to the horseshoe shape. In the arrangement of 
this lesion, the scabs, often quite thick, on removal 
presented a superficial surface of large florid granula- 
tions scantily bathed in serum, and bleeding at slight 
touch. The so-called impetigenous tubercular syphilide. 
3d. Tubercles from size of a grain of pearl-barley to a 
pea, varying in color from pale red to purple, irregularly 
scattered about ; also some larger, quite pustular in ap- 
pearance, some with yellow and others with scabs of 
quite a dark brown color. 



152 PRACTICAL CLINICAL LESSONS ON 

All these had come on so insidiously, so entirely with- 
out pain or even itching, that they had only been 
discovered by the patient to be more than accidental 
pimples a week or so previously, but had evidently been 
present a month or more. The treatment was changed 
from the pil. proto-iodid. hyd. to the mist, biniodid. 
hy drarg.,* a teaspoonful thrice daily. Scabs poulticed off, 
and an ointment composed of nitrate of mercury ung. 
and vaseline, equal parts, applied morning and night. 
Improvement followed, especially in the open lesions ; 
but after a couple of months, when the first crop had 
almost disappeared, others appeared on the right calf. 
Treatment changed to nightly mercurial fumigations 
(20 grs. calomel), and increase in the iodide of potas- 
sium—increasing from eight grains three times a day, 
a drop for each dose, up to sixty, and taken in a tum- 
bler of milk. After several months, taking from fifteen 
to twenty fumigations a month, and keeping the iodide 
at about sixty grains thrice daily, the eruption entirely 
disappeared, leaving slight, pale, depressed, and corru- 
gated cicatrices on the bod}', and deep coppery stains 
on the extremities. The treatment was then omitted, 
the patient still being in good general health. Capsules 
of cod-liver oil and iron (Mathe)' Caylus), adminis- 
tered. After a month or so, other crops, chiefly 
pustular, came to the surface, apparently on the site of 
the former eruptions, and came and went for the next six 
months, getting better in one place and then cropping 
out in groups of half a dozen or so in another, and this 
under a systematic treatment as before mentioned, car- 
ried out with as much regularity and persistence as was 
possible under the circumstances. Relaxing it, for even 
a few days, was followed by more or less return of the 
trouble, and it was fully two years after the appearance 
of the first tubercular eruption before the trouble entirely 
ceased to recur. During this time no points were at- 
tacked except those first mentioned — under the scapula, 
and on the thigh and buttocks, and soon after on the 
right calf ; after this the recurrences were in the same 



* See formula 



, p. 92. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 153 

points or in their immediate vicinity. During the entire 
period covered by the treatment the patient was most 
of his time at sea, under favorable hygienic conditions, 
and living a temperate and regular life. Within the 
last year (1882) the above-mentioned person was seen 
in consultation for what was supposed to be a malarial 
neuralgia. There was no history of any recurrence of 
trouble which could be reasonably attributed to the 
syphilitic influence for the previous five years. The 
neuralgia, which was chiefly in the muscles of the spine, 
after resisting treatment by the iodide for several weeks, 
finally passed away under the influence of a month's so- 
journ in the tropics. 

Remarks. — The chief interest involved in the appear- 
ance of an eruption, after the eighth or tenth month of 
syphilis, is as to whether it is to be accounted as a se- 
quel of the active disease, or is an evidence of the active 
presence of syphilitic cell material in the organism. 
After the first general papular eruption, which, as a rule, 
appears between the third and the seventh month, and 
is more or less symmetrical in its distribution, groups of 
papules may develop on the shoulder or arm or back 
or forehead, which, although usually darker and more 
likely to assume an annular or crescentic form, may pre- 
sent all the physical characteristics of the papules of the 
earlier general eruption. These are known as the recur- 
ring papular syphilides, and are supposed to be the result 
of a release of accidentally imprisoned infective cell ma- 
terial from lymphatic glands, in the immediate vicinity 
of the eruption, and to indicate a continued activity 
of the contagious element.* 

It is quite impossible, in the present state of our knowl- 
edge of this matter, to make a positive diagnosis in cases 
of doubt, until sufficient time has passed to observe the 

* " The secretions of syphilitic lesions are found to consist of a serous 
fluid containing numerous shining granules or molecules, which are 
masses of protoplasm or germinal matter holding the contagious proper- 
ties of syphilis. These microscopic bodies are probably taken into the 
circulation by the lymphatics and conveyed over the body." (Bumstead 
and Tavlor on the Venereal Diseases, fourth edition. Henry C. Lea, 
Phila., 1S79. P. 443.) 



154 PRACTICAL CLINICAL LESSONS ON 

manner in which the tissues occupied by the eruption, 
are affected by the presence and the final absorption of 
the material causing it. Thus the papule, having its 
origin in an accumulation (proliferation in loco?) of 
germinal cells (commencing, according to Kohn and 
others, always in a papilla cutis), has several character- 
istic points, i st. In certains cases the cells thus crowded 
together " are not destined to become permanently or- 
ganized, as they degenerate and disappear, or assume a 
dull granular appearance, undergo fatty degeneration 
and are absorbed. Or they may become heaped to- 
gether in the form of detritus and form pus." * 

Thus they either " undergo fatty degeneration and 
become absorbed," leaving no loss of tissue to mark their 
site, or they become pustules. The tubercle, on the other 
hand, is made up of the so-called "gummy" or germinal 
material, identical with that found in the lymph channels ; 
arrested by localized obstruction of such channels; this 
localized accumulation causing absorption of the tissue in 
which it is located, finally itself undergoing fatty degener- 
ation and absorption, a depression or cicatrix is left which 
is a sure diagnostic mark of the uncomplicated syphilitic 
tubercle. f These so-called " gummy exudations," char- 
acterizing as they do all the sequelae of syphilis (the 
secretions of which are non-contagious), form the dis- 
tinguishing feature between syphilis, as a contagious 
disease, and its sequelae. Their occurrence, in what- 
ever locality or form, calls for change or modification 
in the treatment. Iodine and the iodide of potassium 
having been found to possess a peculiar power in caus- 
ing the fatty degeneration and elimination of the so-called 
gummy material is then found promptly efficacious in 
aiding in the cure.J 

* Caracteres cliniques et histologiques des Syphilis, par Moritz Kohn, 
Wiener Wochenschrift. Caracteres, 1870. No. 55, Archives Ge'ne'rales de 
Me'decine, March, 1872. 

f See Van Buren and Keyes, Genito-Urinary Diseases, with Syphilis, 
page 583. Appleton & Co., New York, 1874. 

X As these processes are quite distinct in their origin they may be pres- 
ent at one and the same time, and thus it may occur that although the 
tubercular eruption — a sequel of syphilis — is present, the contagious ma- 
terial represented by the papule may still exist in the organism ; the 



SYPHILIS AND THE GENITOURINARY DISEASES. 1 55 

The punctate form of the tubercular syphilide, as first 
described, is usually the earliest of the syphilitic se- 
quelae, and rarely appears after the third year. The su- 
perficial ulceration, with a tendency to the crescentic, or 
horseshoe arrangement, is next in order, and, is occasion- 
ally associated with it, as in the foregoing case, but may 
occur as late as the tenth and even the twentieth year 
after infection, and is likely to be especially severe and 
extensive in cases of chronic alcoholism. 

Tubercles occasionally appear singly, or in small 
groups, on the face, especially on the alas nasi, and, ulcer- 
ating superficially, become scabbed over and pursue a 
very sluggish course, often for many months, and are 
uot unfrequently mistaken for simple lupus. Under 
favorable hygienic conditions, all these forms yield 
promptly to treatment : locally, by iodoform, or the ung. 
liydrarg. nitratis and vaseline ; and internally by com- 
bination of mercury and the iodide of potassium, as in 
the misturae biniodid., and additional iodide of potas- 
sium in doses increasing by one drop at each dose up 
to 60, thrice daily, if well borne, always taken well di- 
luted — in half a tumbler, and finally a tumbler of fluid, 
preferably of milk. In this way the stomach is rarely 
rebellious to the maximum dose. 

It is a fact well understood by all who have experi- 
ence in the tubercular forms of syphilis, that local meas- 
ures, while apparently hastening the cure, are almost 
wholly useless, except in combination with mercury 
and the iodide of potassium. It is also equally appre- 
ciated that while prompt benefit, is almost certain to 
follow the use of the iodide of potassium, recurrences 
of the trouble are much more frequent, than when this 

limit of contagion in acute syphilis having been ascertained in the very 
greatest majority of cases not to exceed three years. Bearing this in 
mind, it may then be said that although the presenting lesion being tuber- 
cular and by its origin illustrating the non-contagious stage of syphilis, 
yet it cannot be claimed as free from virulence (i.e., power of contagion) 
until two or more years have passed and all gland enlargements depen- 
dent upon syphilis have disappeared ; but that after such proof of the ter- 
mination of the acute stage of the disease, the presence of such tubercular 
eruption would not indicate a power to transmit syphilis by direct con- 
tact or through heredity. 



156 PRACTICAL CLINICAL LESSONS ON 

remedy is used in combination with a mild mercurial 
treatment, either internally or by innunction or fumiga- 
tion. Such behavior, which is recognized as a clinical 
fact, is most significant of the conditions which demand 
treatment. The accumulations of the arrested germinal 
material, or so-called gumma, as the immediate recog- 
nized cause of the local lesions, are readily acted upon 
by the iodide of potassium, (the weaker agent in pro- 
ducing tissue metamorphosis), while the permanence of 
results is better secured by the mercurial, which has the 
greater power to cause a modification, if not a complete 
metamorphosis of the material causing the obstruction. 
In the absence of absolute proof, as to the degree and 
quality of the obstruction in the lymph channels, it may 
be possible, that this is due, in some cases, to actual clo- 
sure by cicatricial deposit, such as is seen constricting 
the parenchymatous structure of the liver, the tes- 
ticle, etc. If this is the fact, removal of such obstruc- 
tive material by any sort of treatment is scarcely prob- 
able. This would account for the repeated recurrences 
of trouble, temporarily relieved by treatment, and con- 
stituting a form of what is termed a syphilitic dyscrasia. 
It may also be possible, that, where such cicatricial ob- 
literation of lymph channels is not extensive, the circu- 
lation is temporarily relieved by elimination of the 
excess through treatment, or through fatty metamorph- 
osis, sua spoilt e, until the dilatation of adjoining or sub- 
sidiary efferent channels shall afford permanent relief. 
It is a clinical fact that, as in the foregoing case, relapses 
continue to occur for years even, and the case is at 
last permanently cured by efficient treatment: while in 
others, the troubles, with or without treatment, remain 
until the termination of the life of the patient, notwith- 
standing the most judicious care.* 

* However much the explanation of gummous collections may need 
absolute microscopical demonstration, it is conceded by all modern patho- 
logists: 1st. That the so-called gummous material constitutes in some way 
the sum and substance of all the tertiary and quarternay lesions: in other 
words, the sequelce of syphilis. 2d. That this material does not differ mi- 
croscopically in any appreciable way from the normal germinal elements, 
such as are found in all the lymphatic gland, channels, and spaces in the 
human organism. If, then, this material present to a certain degree in all 



SYPHILIS AND THE GENITO-URINARY DISEASES. 1 57 

Case III. W. McN. ; merchant ; 42. Temperate, or- 
dinarily healthy ; had a well-marked open initial lesion 
of syphilis at 25 years of age. This was followed by a 
general papular eruption, at about the fifth month. Treat- 
ment desultory, until the appearance of the eruption, 
when he came under my observation, and was put upon 
pil. duplex (mass, hydrarg. et ferri). This treatment was 
well borne, and continued for a year and a half very 
steadily ; occasional intermissions of a few days only, 
when slight evidences of mercurialism occurred. With 
the exception of several mucous patches in the mouth, 
and slight ulceration of the tonsils,during the sixth month, 
there were no open lesions of any sort. General and local 
gland enlargements had declined satisfactorily. The 
patient at this point was put upon the mist, biniodid. hyd. 
(potas. iodid. 8 grs., hydrarg. biniodid. -fa), a teaspoon- 
full thrice daily, and it was faithfully continued for the 
following six months. During this time the patient was 
apparently in perfect health. At its close, the only evi- 
dence of syphilitic trouble, was the abnormal, but not 
greatly enlarged, lymphatic glands, at all characteristic 
points. As these glands had not diminished, appreciably, 
during the last six months of treatment, it was concluded, 
in the absence of knowledge of their condition before 
the accession of syphilis, that they had no longer any 
pathological significance, and all treatment was sus- 
pended. During the following two years, no evidence 
of syphilis having been manifest, permission to marry 
was accorded. Child born a year after ; mother and 

the tissues — for all tissues are supplied with lymphatic spaces or channels — 
becomes localized in excess at certain given points, this can logically only 
occur by the obstruction of such channels or spaces. Whether we can 
yet demonstrate this microscopically or not. It is within the last ten 
years that even the existence of lymphatic vessels in the most important 
parts of the body — as, in the eye, in the bones, etc. — has been denied by 
leading and accepted authorities. But since then it has been proven by 
Thin. Ludwig, Schweigger-Seidel, and others, that there is not alone a gen- 
erous supply of lymphatic vessels to the eye and the bones, etc., but even 
cartilages are abundantly furnished with them. Accepting thus a legiti- 
mate deduction from known facts, which furnish logical reasons for the 
plan and measure of treatment, we may wait hopefully for the microscop- 
ical advances which shall scientifically establish our knowledge of the 
exact mechanism of the late lesions of syphilis. 



158 . PRACTICAL CLINICAL LESSONS ON 

child healthy — and so continued. Two years subsequent 
to the birth of the child, and thus six years from the ac- 
quirement of syphilis, patient presented with a swelling 
over the lower portion of the sternum, about the size 
of half a lemon ; quite firm ; slightly tender on pres- 
sure. First noticed, about half its present size, about a 
month previous. Diagnosis : gummy tumor — a sequel 
of former sy philis. Treatment : iodide of potassium 8 
grs., biniodid. of mercury one sixteenth, three times a 
day. As the patient was otherwise in good health, noth- 
ing further was prescribed. Without any local applica- 
tion, under the above-mentioned treatment, the tumor 
declined rapidly, and at the end of three months 
every evidence of it had completely disappeared, and all 
treatment was discontinued. A little more than ten 
years have passed, and no further trouble of syphilitic 
nature has occurred, either to the patient, his wife, or 
his children, of which latter he has several. 

Remarks on Case III — Claims for the non-contagious 
character of syphilitic sequelae, find corroboration in 
this case. Prompt effects of the specific treatment re- 
move any possible doubt as to syphilitic origin of the 
trouble. The cessation of treatment on the entire 
disappearance of the tumor, is in accordance with the 
usual practice in such cases, but it must not be for- 
gotten that such tumors are likely to return, or that 
similar accumulations may occur at other points. And 
while, as in this case, a prolonged immunity may be ac- 
quired, even escape from any further syphilitic sequelae, 
yet such an accident, indicating failure of treatment dur- 
ing the active stages of syphilis to completely efface the 
damage then done, must make the patient and his phy- 
sician anxious and watchful for possible similar develop- 
ments in other localities. Especially should this be 
borne in mind when obscure troubles of nutrition or 
of the motor or sensory apparatus are recognized. 

GUMMA OF THE TESTICLE. 

Case IV. J. V., 65 ; lawyer, in good general health. 
Presented with an enlargement of the left testicle. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 1 59 

It had a few weeks previously attracted his attention 
by its weight, and not from any pain in it. The size of 
the organ, which was ovoid in shape, was four inches 
in its vertical and three in its horizontal diameter, 
quite firm and insensitive to the touch. A small 
amount of fluid was recognized in the tunica vaginalis. 
There was no history of any urethral disease or any 
mechanical injury either to the testicle or the sur- 
rounding parts ; but there was a tolerably clear history 
of syphilis at the age of 24, viz.: a sore coming on the 
penis fully three weeks after a suspicious connection, 
which remained for some time, finally healing under the 
internal administration of mercury. He married a few 
years after ; had several children ; also grandchildren ; 
not one of whom had ever any recognized signs of 
syphilis. No recognized sign of syphilis had appeared 
in the patient from the date of the healing of his sore, 
to the occurrence of the swelling of his testicle, forty 
years after. The tumor, both as to its accession and 
its physical characteristics, was like a sequel of syphilis. 
Freedom from pain, and from irregularities in shape ; 
freely movable under the scrotum : unconnected 
with any tubercular or cancerous antecedents. About 
four drams of serum were drawn from the tunica vagi- 
nalis and the smooth surface of the tumor, and com- 
plete freedom from fluctuation was made more manifest. 
Treatment by the mist, biniodid. internally, was com- 
menced, together with ung. hydrarg. mit. externally. 
Subsidence of the tumor commenced within a fort- 
night, and at the end of six months the testicle had re- 
sumed, nearly or quite, its original size. 

Remarks. — The absence of all recognized manifesta- 
tions of syphilis, as in the foregoing case, is not without 
precedent. Early constitutional syphilis varies in its 
intensity as much as any other known disease. The 
roseola, even if present, may readily escape observation. 
The papular eruption may be confined to half-a-dozen 
points, or even a single spot on the body, or a single mu- 
cous patch or tubercle, which shall pass away without 
treatment or recognition, and yet syphilitic sequelae may 



l6o • PRACTICAL CLINICAL LESSONS ON 

occur, the effects of which may prove as grave as when 
every phase of the active period presents the typical 
manifestations. Once recognized as syphilitic, no matter 
how slight the lesions of the initiatory period or that of 
general infection, the treatment should be as system- 
atic, as thoroughly considered and carried out, as 
when well-marked in all respects. It is only in this 
way that we gain the great security against the occur- 
rence of sequelae, and if occurring, secure the lightest 
forms of trouble. Unfortunately, relief from the im- 
mediate and appreciable accumulations constituting 
sequelae (the so-called gummy tumors of syphilis) does 
not always mean cure : recurrences, especially of the 
accumulations in the testes, are not uncommon, as in 
the following : 

Case V. P. P. S. This patient gave a clear his- 
tory of the characteristic eruptions of active syphilis 
occurring twenty years ago. Good health up to five 
years, when his right testicle became enlarged to the 
size of his fist. He stated that under occasional treat- 
ment of iodide of potassium the testicle grew very 
much smaller ; in fact, he thought his difficulty almost 
cured, when the swelling returned. On examination, a 
large quantity of fluid was found in the tunica vagina- 
lis. Four ounces being drawn off, it became evident 
that the tumor remaining, while not larger than a nor- 
mal testicle, was irregular in shape — nodulated — espec- 
ially at the lower portion, where it was of cartilaginous 
hardness. The upper portion alone was sensitive to 
pressure. It thus became evident that a fibrous de- 
generation of the entire inferior portion of the testicle 
had taken place, and that its secretory structure was 
almost entirely destroyed ; the sensitiveness to pres- 
sure indicating the portion which had thus far escaped. 

Remarks on Case V. — In the post-mortem exami- 
nation of similar cases, it is found that two forms of 
trouble frequently (and always in long-standing cases) 
unite in the so-called chronic orchitis of late syphilis, 
the one usually earliest to manifest itself being gen- 
eral infiltration or a localized tumor at one or more 



SYPHILIS AND THE GENITOURINARY DISEASES. l6l 

points in the substance of the organ. This accumu- 
lation is found to be made up of materials charac- 
teristic of the "gummy tumor' occurring in other 
localities. Subsequently to the occurrence of these 
tumors a marked growth of fibrous tissue is found to 
take place, apparently commencing in the lobular spaces ', 
and gradually encroaching upon the seminal lobules 
until they are destroyed. The elements of new forma- 
tion, traversing in this same way the substance of the 
entire organ with a cicatricial net-work, the contrac- 
tion which naturally follows often results in the total 
destruction and almost complete disappearance ol the 
organ. This explains what we find in the present in- 
stance. The history points to a general so-called 
gummy infiltration, involving, probably, the epididymis 
and the body of the testicle, and a later development 
of fibrous tissue, which has, by its subsequent contrac- 
tion, reduced the organ to its present indurated and 
atrophied condition. It is interesting here to recall 
the fact, made prominent by all authorities on syphilis, 
that cicatricial deposit and its subsequent contraction 
and strangulation of the parenchyma of the testicle, 
resulting in true atrophy, is characteristic of the influ- 
ence of late syphilis, and occurs not alone in the testi- 
cle, but notably also in the liver and the kidneys. The 
tendency to formation of fibrous tissue has also been 
recognized (from apparently the same causes) at other 
points, as in the larynx, intestine, etc. Ranvier and 
Cornil significantly remark* that all profound syphilitic 
lesions of the mucous membrane occasion a prolifera- 
tion and a production of connective tissue usually much 
greater than in diseases due to other causes. It is a 
well ascertained clinical fact that gummy infiltration 
precedes the stage of cicatricial deposit, and that while 
both the gummy tumor and cicatricial atrophy, are 
often met with in .the same testicle, general enlarge- 
ment first occurs; then comes the recognition of local- 
ized deposits of gummy material, and later, often sev- 
eral years after, compression, due to contraction of 

* "Patholog. Histol.," page 399, 1880. 



l62 PRACTICAL CLINICAL LESSONS ON 

cicatricial deposit, finally takes place, and atrophy of 
the testicle results. The clinical evidences are strongly 
in favor of considering the gummy exudation as the 
basis of the cicatricial deposit, and the different subse- 
quent conditions, as but stages of the same pathological 
process, terminating finally in atrophy, through cica- 
tricial contraction. In favor also of this view, and as 
affording a possible explanation of the cause and mode 
of formation of the cicatricial deposits in other organs, 
due to late syphilis, we may recall the statement of 
Rindfleisch in regard to the most favorable conditions 
for the development of new cell formations, namely, 
": Contact with tissue and relative rest of the emigrant 
cells induces them first to essay their amoeboid mobility, 
and then to division.'' * But absolute rest, stasis of such 
cells, or of any cells, is necessary for their development 
into tissue. All fibrous or connective tissue is said to 
be made up of the spindle-shaped or connective-tissue 
cells and fibrillar which are simply a higher stage of 
development of the lymphoid cells and corpuscles, 
evolved from and circulating in and through the lym- 
phatic organs, spaces, and vessels. This is exactly the 
essential material of which cicatricial tissue, wherever 
found, is made up, and this is exactly the sort of tissue 
which has caused the mischief in this testicle, and 
which by authorities is accepted simply as one of the 
many mysterious phases of the so-called tertiary period 
of the disease. Only a single condition is lacking, how- 
ever, in order to place this cicatricial deposit, due to 
syphilis, in the line of ordinary pathological conditions, 
and that is, one which will account satisfactorily for the 
presence and quantity of embryonal or formative cells 
in the localities where the cicatricial tissue is subse- 
quently developed, and the causes of their enforced 
accumulation and stasis in those localities, during a 
period sufficient for the formation of such tissue. 

Ludwig and Thomsa f claim to have demonstrated a 



* Rindfleisch, " Path. Hist.," p. 94, sec 77. 

f Strieker, " Human and Comparative Histology," Sydenham ed., vol. 
i.,p. 311, et seq. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 163 

very generous distribution of lymphatic channels in the 
testicle, the liver, and the kidneys, organs in which the 
cicatricial contraction due to the influence of late 
syphilis is chiefly found. Especially are the lymphatics 
claimed to be numerous and ample in the testicle, 
where injections performed upon dogs have shown that 
lobular spaces are simply lymph sacs or lacunae. In 
point of fact, the seminal lobules are literally inclosed 
in lymph chambers, and the reticulation of lymph 
channels not only surrounds, but permeates, every por- 
tion of the testicle and its appendages. The same rich 
distribution is shown also in the liver and kidneys. 
Having, then, the material necessary for the formation 
of cicatricial tissue, and in localities where it is known 
to develop, the essential condition to produce it, is an. 
enforced stasis of cell elements, through interference 
with the lymph circulation of these organs ; in short* 
obstruction of the lymph channels at various points. 

GUMMY TUMORS OF THE INTEGUMENT AND CELLULAR 

TISSUE. 

Case VI. W. W.; 49. Presented three large, sharp- 
ly cut, apparent ulcerations on the inner aspect of 
the right leg just below the knee ; two about two inches 
each in diameter, quite circular, and a third about two 
inches in length, formed by the union of two about an 
inch in diameter. All had penetrated the integument 
completely; the surrounding integument was only slight- 
ly inflamed. Two small tumors just under the integu- 
ment on the outer side of the right thigh, movable under 
the skin, painless, and another nearer the knee, attached 
to the integument, and distinctly fluctuating. Here 
were, then, three characteristic stages in the progress of 
gummy lesions of the integument. There was a clear 
history of syphilis irregularly treated about fifteen years 
previously. Alleged occurrence, four or five years 
previous, of large sores with heavy black scabs upon 
them, chiefly on the legs and arms, which were cured 
by iodide of potassium. Cicatrices paler than the sur- 
rounding skin were found corroborating the statement. 



164 PRACTICAL CLINICAL LESSONS ON 

This patient was in low general condition from dissipa- 
tion, insufficient nutrition, and bad hygiene. He was 
given nutritious diet, with cod liver oil. A course of 
iodide potassium with biniodide hydrarg., the former 
to be gradually increased by the addition of a grain at 
a dose, taken largely diluted with milk, up to sixty 
grains. Under this treatment and care, with local appli- 
cations of iodoform in powder to the ulcerations, 
marked improvement at once took place, and in about 
two months healing of the open lesions was com- 
plete, and the tumors were apparently absorbed. 

Remarks on Case VI. — As a rule, to which excep- 
tions are rare, the ulcerative forms of syphilitic sequelae 
occur in those cases which have either been imperfectly 
treated or not treated at all in the early active form of 
the disease. It is also true that, while the gravest acci- 
dent may occur to those who have had the lightest 
forms of early manifestations, the destructive sequelae 
are usually associated with a history of profuse and re- 
curring eruptions in the early stages of the disease. 
It will be found that whatever the form or locality of 
the lesion of late syphilis, the ability to assimilate 
large doses of the iodide of potassium without inter- 
fering with the digestion, is a guarantee of rapid bene- 
fit from its use. Very great care, then, is necessary to 
introduce this potent remedy so gradually and so well 
diluted with milk or some agreeable tonic diluent, that 
the digestive apparatus may be educated to tolerate 
the drug. Fortunately, in cases where it is required, 
iodism rarely occurs in any troublesome degree when 
sufficient care has been exercised in this respect. The 
substitution of pure iodine in plain molasses, or with 
starch, has been previously suggested, when the iodide 
of potassium is not tolerated. 

PSORIASIS OF TONGUE, FOLLOWING SYPHILIS. 

Case. N. M. W.; 30. At 22 had an initial lesion of 
syphilis, which remained unhealed under local applica- 
tions up to the fourth month after infection. It was 
then excised. Healing took place by first intention: 



SYPHILIS AND THE GENITOURINARY DISEASES. 1 65 

several small mucous patches were then present in the 
mouth and on the tongue ; the superficial lymphatic 
glands were enlarged and indurated at all usual locali- 
ties. The patient was put upon pil. duplex (hyd. mass. 
2 gr., ferri sulph. exsic. 1 gr.) thrice daily, and this 
3vas continued, somewhat irregularly — omitting several 
times for several weeks, whenever some tenderness of 
the gums appeared — for a year and a half. No inter- 
current lesions during this time. Glands still some- 
what enlarged ; mist, biniodid. hyd. (potas. Iod. 8 grs., 
hyd. biniodid. T V), a teaspoonful as a rule thrice 
daily, but not seldom neglecting it, for the following six 
months, when no further evidences of syphilis having 
developed — the patient in excellent health — treatment 
was suspended. Not the least sign of syphilis for the 
next four years, when slight soreness of the right side 
of the tongue appeared, chiefly along the edge. This 
was attributed to the excessive use of cigarettes, to 
which the patient was addicted. On ceasing this there 
was immediate improvement in regard to the soreness, 
but a pale, thin pellicle, appeared in two spots on the 
tongue, about the size of a split pea, a thin film along 
the edge, and a patch of the same, as large as a dime, on 
the inferior surface of the same side, and all within a 
few days. The patient was put again upon the binio- 
dide mixture, and took it faithfully for several weeks, 
making applications locally with a saturated solution of 
nitrate of silver, every day or two, without any very 
decided benefit. In point of fact, the spots on the 
tongue became slightly elevated and whiter, apparently 
from accumulated epithelium, giving the characteristic 
appearance of a simple psoriasis of the tongue. An 
application to these spots with Paquelin's gas cautery, 
the platinum point at a white heat, was carefully made, 
and the internal treatment continued. The result was 
an immediate improvement in the appearance of the 
spots, and after the second application, about a week 
after the first, the patches were quite freed from the 
pellicle. The patch under the tongue was then treated 
in the same manner, carrying the cauterization as far as 
possible through the thickness of the pellicle, subse- 



l66 PRACTICAL CLINICAL LESSONS ON 

quently simply brushing the platinum point quickly 
over the surface. Altogether, half-a-dozen applications 
were made in the course of four weeks, at the end of 
which time there was complete disappearance of the 
pellicle, and scarcely a trace of the lesion remained. 
The internal treatment was suspended, and at the end 
of three months, there was no indication of return of 
trouble. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 167 



LESSON XVIII. 

Significance of psoriasis of the tongue, following syphilis; often mistaken 
for mucous patches of the active stage of syphilis, and when occurring 
after the first or second year, called chronic mucous patches. All lesions 
of late syphilis, of the same significance's to their contagious property. 
All caused by accumulations of so-called gummy material, or non-con- 
contagious lymphatic matter. So-called chronic mucous patches of 
tongue usually caused by use of tobacco. The authority of M. Four- 
nier, favoring the view of their capacity for contagion. Case quoted by 
him in illustration. Analysis of M. Fournier's case, and arguments to 
show its failure in proving the inoculability of late chronic lesions of 
the tongue, and also from Fournier's work and other valued authori- 
ties to show, that no form of syphilitic lesion, is contagious after 
the fourth year. This position supported by the teachings and experi- 
ence of M. Fournier, in his work on syphilis and marriage. Marriage 
proper after a certain period. Strong statements of M. Fournier to 
this effect. Syphilis constitutes only a temporary bar to marriage. 
Fournier adduces eighty-seven cases in proof of this. Tertiary 
lesions shown not to be capable of transmitting syphilis. Exceptions 
claimed, lacking authentic proof. Fournier's case, cited to prove infec- 
tion from lesions present after three or four years, inadmissible. An- 
alysis of evidence. Case adduced in rebuttal. Case cited to illustrate 
sources of error. What is needed is a guide, as to time, when syphilitic 
patient may be considered free from danger of communicating the dis- 
ease. Facts and arguments to show that this time, is not necessarily 
more than three or four years. Sources of error in claiming infection 
beyond this time. Cases in illustration. 

Remarks. — The foregoing case would, I think, be 
best characterized as a psoriasis, induced by tobacco, 
causing irritation of a surface predisposed to such 
action, by the previous occurrence of local syphilitic 
lesions at this vicinity, during the active period of the 
disease. It has been in my experience to see quite a 
number of such cases, with or without superficial ulcera- 
tive lesions, and which had been classed, by previous 
medical attendants, as chronic mucous patches, with the 
distinct understanding that they possessed the power of 
communicating syphilis. It should be understood that 
mucous patches, are simply papules, occurring on mu- 
cous membrane, and cannot exist as specific lesions 
after the active stage of syphilis has passed. It may, I 
think, be safely stated, that, after the third, and at 



l68 PRACTICAL CLINICAL LESSONS ON 

farthest after the fourth year, lesions of the mouth of 
whatever character, — either superficial glossitis, which 
is recognized by oval or circular, small or large patches, 
or tubercles of thickened sub-mucous cellular tissue ; or 
the deep glossitis, which causes a general hyperthropic 
thickening, — are due to accumulations of gummy mate- 
rial, so-called; and, whether accompanied by ulcera- 
tions, superficial or deep, are of the same nature as all 
the other lesions of so-called tertiary or late syphilis, 
which have been incontestably proven to be free from 
the contagium of syphilis. The occurrence of super- 
ficial erosions of the tongue, from a few to many years 
after the termination of the active stage of syphilis, is 
not infrequent. The habitual excessive use of tobacco, 
has seemed to me more likely to produce superficial 
ulcerative lesions, than where syphilis has not been ex- 
perienced, especially where the lesions of the active 
disease have occurred in the mouth. Often, in such 
cases, simple abstinence from tobacco, will cause such 
ulcerations to heal, without further trouble. In other 
cases, the iodide of potassium acts quickly to relieve, 
but, in all, the apprehension of communicating syph- 
ilis is an ever-present horror, and when, as is some- 
times the case, such ulcerations, either from vices in the 
digestive processes, or from permanent cicatricial dis- 
turbances of the affected tissues, continue for years, 
the condition of such patients is sometimes, indeed, 
pitiable. It is true that we have the weight of an 
authority, so great as M. Fournier, in support of the 
possibility, nay, the probability, of infection of syphi- 
lis for many years, or, indeed, indefinitely in such 
cases, as is shown in the following, quoted from his 
popular work on " Syphilis and Marriage." * " These 
lesions are always superficial, limited, and mild. They 
are readily cured by cauterization, aided by some local 
care ; but they are only cured to be reproduced, — to re- 
new themselves incessantly. In themselves they are of 

* "Syphilis et Manage." Lecons Professees a l'Hopital Saint Louis. 
Par Alfred Fournier, Professeur a la Faculte de Medecine de Paris, 
Medecin de l'Hopital Saint Louis, Membre de l'Academie de Medecine. 
Paris, 1880. Page 122. 



SYPHILIS AND THE GENITOURINARY DISEASES. 169 

no importance, but they become only the more danger- 
ous in respect to contagion. Such, for example, is the 
case of a patient whom I treated some time ago. This 
young man had been infected with a syphilis, five years 
before, which one could fairly call mild, since the initial 
chancre was only followed by a roseola, a palmar syphi- 
lide of slight intensity, and a sore throat. He treated 
it almost from the beginning sufficiently well ; several 
times he submitted, under my advice, to a strong mer- 
curialization (15 to 20 centigrammes of proto-iodide 
daily). Well, in spite of this treatment, and in spite of 
all my efforts, the patient (who, by the way, is a smoker : 
a circumstance essential to note) has not ceased to be 
affected, during a period of five years, with lingual syphi- 
lides almost continuously. I cured him of one breaking 
out ; one or two months later a new one attacked the 
tongue ; then came a new treatment, followed by a new 
cure ; then reappearance of the malady, and so on. 
To be brief, I always cured him, and ' it always began 
again,' to use his own expression. Now that he has 
completely given up tobacco, at my earnest solicitation, 
the eruptions become less frequent, but have not alto- 
gether ceased ; and quite lately I have again seen him 
with syphilis coming on the back part of his tongue. 
Now, what would have happened if, relying on the 
mild nature of his disease, and satisfied as to the treat- 
ment followed, I had allowed the patient to marry be- 
tween the two outbreaks of such symptoms? What 
would have happened, I need not predict theoretically, 
because I have had a practical demonstration. This 
young man took as a mistress, last year, a woman who, 
till then, was perfectly healthy : exempt from every 
venereal symptom. Some weeks later he brought her 
to me, affected by an indurated labial chancre, mani- 
festly received from the lingual syphilides of the 
patient." 

This case is presented as a typical one, to illus- 
trate the possible persistence of contagious lesions 
after many years, notwithstanding the disease is of 
mild form, and has been systematically, persistently, 
and efficiently treated from " almost from the begin- 
ning." 



lyQ PRACTICAL CLINICAL LESSONS ON 

It will at once be seen, that, as such lesions of the 
mouth may appear, several years after the apparent 
cure of syphilis, no real guarantee against the dan- 
ger of communicating syphilis, for a very long period 
of years, can ever be given, and if such guarantee can- 
uot be given, no man, it appears to me, lias ever a right 
to advise, or even to consent to, marriage of a person 
who has once had syphilis. It becomes a matter of 
vital importance to know, whether or not, there is a 
form of late lesion of syphilis, which, unlike alL other 
late lesions, still retains the power of infection. 
M. Cornil says (p. 34, Am. ed. 1882): "The inocula- 
tions made by Diday render it probable that tlie tertiary 
lesions are not inoculable, and consequently not contagious? 
Bumstead & Taylor (ed., 1879, P- 443) : "Hence we con- 
sider the blood a7id the secret io7ts in tertiary syphilis i?i- 
nocuous? Hill & Cooper (London, 1881, p. 11), say: 
" All attempts to propagate the disease with secretions 
taken at this period have failed!' Baumler says of the 
cessation of the innoculable stage of syphilis : " This 
takes place in the majority of cases, and at the expira- 
tion of eighteen months or tzvo years the infection is en- 
tirely exhausted? (Ziemssens's " Encyclopaedia," Am. 
edition). 

The most complete and irrefragable evidence, in 
favor of the view that the injective power of syphilis 
is self-limited, and does not extend over a period 
of more than three or four years, is that presented 
by M. Fournier, in his recent work on " Syphilis and 
Marriage," adduced to justify his previous statement 
of opinion, that persons having had syphilis under 
certain circumstances may marry. The statement, a 
very strong one, appears on page 18 of his work, thus : 
" Then, yes ; a hundred times, yes : one may marry after 
having had syphilis, and the results of such a marriage, 
contracted under these conditions, may end absolutely 
happily, medically speaking. This I affirm, and fear- 
lessly proclaim from the house-tops, after having con- 
cientiously studied this grave question, both clinically 
and socially, and after having religiously consulted num. 
bers of observations of my own and others. It is for 
me an absolute fact, an undeniable truth;" and at page 



SYPHILIS AND THE GENITO-URINARY DISEASES. 171 

15, ibid.: "The truth is that, with some very rare ex- 
ceptions, syphilis only constitutes a temporary bar to 
marriage." In support of this positive opinion he says,* 
" For my part alone, I have in my hands, to speak only 
of written facts, eighty-seven observations relative to 
syphilitic subjects, undoubtedly syphilitic, who, having 
married, have never communicated to their wives the least 
suspicious phenomenon ; and, moreover, these eighty-seven 
have produced among them a total of one hundred and 
fifty-six absolutely healthy children." 

In examining the clinical records of these eighty- 
seven cases, given at page 231, et seq., of his work, we 
find that thirty-six out of this number of men who were 
thus proven free from any power to transmit syphilis, 
either by direct contact or by heredity, were subjects 
of late or tertiary lesions of syphilis after marriage — 
some before and some after the birth of children. 

These lesions comprise almost all the accidents of late 
syphilis, thus : gumma of penis, palmar psoriasis, dry 
tubercular syphilide, gumma of velum paluli, cerebral 
syphilis, papulo-tubercular syphilide, and costal perios- 
tosis, cerebro-spinal symptoms (evidently of specific 
origin), diplopia, passing attacks of hemiplegia, nasal 
syphilides, ecthyma of legs, specific tibial periostitis 
and glossitis, specific sarcocelele, nasal ulcers, ulcerative 
laryngitis, papulo-squamous palmar and plantar syphili- 
des, sclerous glossitis, papulo-scabby svphilides of cir- 
cinate form, tubercular ulceration, syphilide of nose. 

This would appear to be sufficient evidence that M. 
Fournier, presenting these cases to show that they lacked 
entirely the contagious element, was a firm believer in 
the non-transmissibilitv of svphilis from late lesions. 

Another case, quite in line of the first case cited — which 
seemed to prove indefinite capacitv for infection, appears 
inadvertentlv to have slipped into M. Fournier's 87 cases. 
This is Case XLIX. (p. 237 ibid.). Thus runs the clinical 
history : " Hard chancre, roseola palmar, psoriasis, syph- 
ilides of the mouth ; iodide treatment ; no mercury. 
Married four years after infection ; wife remained free ; 

"'Fournier, " Syphillis et Mariage." Ibid., p. 16, also p. 231. 



172 PRACTICAL CLINICAL LESSONS ON 

two healthy children. After the birth of the second child 
the husband infected the wife through a sypJiilide of the 
mouth ; pregnancy the following year ', which ended in a mis- 
carriage." 

Lacking- any other explanation from M. Fournier, 
this case would, then, appear to be, like the first case pre- 
sented, one where a late lesion of the mouth had com- 
municated syphilis, and this at least seven years after 
the original infection, and even after several years of 
marriage, during which the wife had escaped, and two 
healthy children had been born. Exceptions of such 
vital importance — the first cited as a typical exception, 
and the second supporting it with great force — in or- 
der to be accepted, should, it appears to me, be quite 
free from reasonable doubt, on all essential points. Let 
us examine them as critically as these meagre details will 
permit. 

In the first case, after a mild and thoroughly treated 
syphilis, in a patient who was an inveterate smoker, les- 
ions of the mouth recurred constantly, for a period of 
five years, influenced only temporarily by treatment — 
promptly benefited by leaving off his tobacco. Physician 
(M. Fournier) fears that this lesion is an exception to 
the lesions of syphilis which occur at so late a period. 

M. Fournier's experience in regard to inoculability, 
at so late a period, are given in his work, as at p. 101, 
where he says : " In those cases where I have seen 
syphilis pass directly from the father to the child, 
without contamination of the mother, I have always ob- 
served, that the paternal infection, was of a comparatively 
recent date, that is to say, had not exceeded the maxi- 
mum of three or four years. Beyond that time I have 
never firmly established the transmission of syphilis by 
paternal heredity."* Again at page 132: "A patient 
comes to us in the full secondary period, and we submit 
him to the usual treatment. Now, what occurs, nineteen 
times out of twenty at least? First, that the patient is 
subjected for some months — even for the first year — to 
secondary eruptions, more or less numerous, more or less 

* Italics my own. F. N. O, 



SYPHILIS AND THE GENITO-URINARY DISEASES. 1 73 

intense, corresponding to the quality of the diathesis, 
but generally mitigated and lessened by treatment. And 
beyond — from about the second year — these eruptions 
continue to decrease . . . Then, still later, the lessening 
is more marked, or becomes complete with the third, or, 
later, with the fourth year. From that time, the secondary 
period is done, and, with it, the contagious accidents 
which accompany it, and which constitute the principal 
dangers of marriage. Such is the rule : that this rule 
has exceptions I know but only too well; and I have 
already given examples of such exceptions" (p. 122 ibid.), 
[case above cited]. In this case a young man takes a 
mistress, who some weeks later presents with an initial 
lesion of the lip. The conclusion appears to have been 
promptly arrived at on the following basis, viz.: possi- 
bility of contagion from patient's buccal erosions, (which 
did not yield to anti-syphilitic treatment, but which did 
improve when tobacco was withheld) ; probability that 
the mistress acquired her labial chancre from the secre- 
tion of this very exceptional kind of syphilitic lesion, if 
it was syphilitic. 

Now, is such a conclusion sufficiently warranted by 
this evidence, on a matter of such moment ? Let us look 
at other causes, equally possible, equally probable. The 
young man did not take for a mistress, a woman whose 
virtue was above suspicion. Such a coincidence as 
the contact of such a woman's lip, with some other lip, 
with fresher syphilitic lesions, would not be so extraordi- 
nary, as the acquirement of syphilis, from a buccal les- 
ion, five years after infection. Such a woman, would be 
quite in line of coming in contact with persons having 
active syphilis, and, either directly or by mediate con- 
tagion, might have acquired her labial chancre, even if 
she had not become this man's mistress, without exciting 
especial comment. 

Let me here place in contrast to this, a case taken 
from my own experience. A young man had undoubted 
syphilis — characteristic initial lesion, general gland en- 
largement, roseola ; no pronounced papular eruption ; 
mucous patches on tongue and inner surface of cheeks. 
After a somewhat desultory treatment of two years, 



174 PRACTICAL CLINICAL LESSONS ON 

he was apparently cured. Remained well for two 
years; began to have ulcerations at side of tongue, thin 
pearl-colored at edges; characteristic appearance of 
the so-called chronic mucous patch ; was greatly ad- 
dicted to tobacco — tongue resisted local treatment, 
unless accompanied by exclusion of tobacco ; repeated 
recurrences for nearly five years ; not markedly affected 
by specific treatment, which was tried from time to 
time. At last he married a virtuous girl, since when 
already two years have elapsed, and she has not yet ac- 
quired syphilis. 

In regard to M. Fournier's second case: this is ren- 
dered especially remarkable, by the fact, that, besides the 
alleged acquirement of syphilis, by the wife, from a buc- 
cal syphilide in the husband seven years after infection, 
that without any specific treatment, the wife remained 
free from syphilis during the earl) 7 years of marriage, 
and, besides, gave birth to two healthy children during 
this period. The acquirement of syphilis, from other 
and unsuspected source, would be much more in accord- 
ance with the probabilities of this case, than that this 
most extraordinary development of active syphilis, upon 
a diathesis which had slumbered through the initiation 
and development of two healthy children, should break 
out finally in infective buccal lesion. The theory of 
re-acquirement of syphilis, from a fresh source, is not so 
difficult to accept. 

The experience and teaching of all the leading author- 
ities, to-day, are against the acceptance of any claim for 
inoculability of the secretions of syphilitic sequelae, and 
any cases, militating against this view, should be free 
from suspicion of imperfect observation, imperfect 
facilities for observation, and from conclusions not based 
upon thoroughly well-authenticated facts. 

Case — on page — will show how easily active syphi- 
lis in a wife may appear to have been acquired from a 
husband who had had syphilis many years previously — 
and yet, against all presumtive evidence, she may be final- 
ly shown to have acquired the disease in a manner more 
in accordance with all that is now positively known of 
the disease. The evidence in favor of the innocence of 



SYPHILIS AND THE GENITO-URINARY DISEASES. 175 

M. Fournier's females was no greater than in my case, and 
yet the latter was proven guilty out of her own mouth. 
What the profession needs now, more than anything 
else, is some reliable guide towards the formation of an 
opinion, as to the time it is necessary to treat syphilis, 
before the patient may be considered free from the dan- 
ger of communicating the disease to others. It would 
seem probable, that an explanation of the course pur- 
sued in M. Fournier's 87 cases might afford light on this 
matter. In point of time we find that the average time 
of marriage in the 87 cases was 5^ years, that 25 per 
cent were married within three years after infection, 
and over 10 per cent within two years. In regard to the 
length and quality of treatment: over 12 per cent of 
the 87 cases had a treatment of less than a year's dura- 
tion, several with only a few months, one with the 
iodide of potass, only, and another with no treatment at 
all (marriage seven years after infection). It would ap- 
pear, then, that the contagious element of syphilis is not 
necessarily dependent upon treatment for its eradication. 
This would confirm the claim made in the earlier pages 
of this work, that syphilis, in its contagious phase, is self- 
limited, and that the value of a prolonged and systematic 
treatment, consists chiefly, in its power to prevent that 
damage to the tissues and organs of the body, which may 
finally eventuate in important lesions in after years, viz., 
the seqnelce of syphilis in their various forms. The 
time during which the treatment should be continued 
should certainly cover all that period, during which the 
affected organism contains any contagious element.. 
This question must be settled by clinical observation. 
If we find that there are well-authenticated cases of 
communication of the disease, after many years, without 
re-infection* and that we cannot tell by the degree or 
quality of the syphilis, what cases may behave in this 
manner, we are then assuming unwarranted responsi- 
bility, in allowing any persons with syphilitic antecedents 
to marry. If, however, we can find by strict scrutiny 

* For facts and arguments showing that re-infection of syphilis is not 
infrequent, see Cornil on Syphilis, Am. ed. : Henry C. Lea's Son, Phil., 
1882, p. 19. 



IJ6 PRACTICAL CLINICAL LESSONS ON 

that such cases are not only very rare, but are not well 
proven, we are then justified in assuming the known 
facts, as ascertained by the experience of the best ob- 
servers, as a basis for our decision. For instance, in the 
great and well-considered experience of M. Fournier 
we find the following statement (p. 101 ibid.): 

" In those where I have seen syphilis pass directly 
from the father to the child without contamination of the 
mother, I have observed, that paternal infection, was of 
comparatively recent date, that is to say, that it had not 
exceeded the maximum of three or four years. Above that 
term, never have I firmly established the transmission of 
syphilis by paternal heredity." Again (p. 101 ibid.): 
" If not always, at least in the enormous majority of 
cases, the husbands who communicate syphilis to their 
wives, are those who have married with a syphilis 
still young : that is to say, with a syphilis which does 
not date back more than a fezv months or a year, perhaps 
tzuo : more rarely three or four!' It is in regard to such 
points, that the profession need exact observation and 
information. While we are prepared to accord much 
value to such statements as the foregoing, from so 
valued an authority, and to accept them as aids to judg- 
ment, to be rendered in practice : we are left in some 
doubt on account of the mode of expression used. " If 
not always," intimates that M. Fournier has seen cases 
where husbands have communicated disease when the 
disease was not recent : that is to say, within four years. 
He does not cite a well-authenticated case in his own 
experience. In more than thirty years' experience I 
have never seen such a case, nor any account of one, 
which would, with fair scrutiny, warrant the claim that 
it was well authenticated. The time of treatment of 
the active stage of syphilis, is a most important one, for 
the profession to be agreed upon. As to the means and 
mode they are quite in accord. It may be safely said 
that all authorities are also agreed, that the treatment 
should be persevered in, as long as any tangible or ap- 
preciable evidences of the disease remain. In America, 
the steady, gentle mercurial course, continuing through- 
out the usual period of active manifestations, and not less 



SYPHILIS AND THE GENITO-URINARY DISEASES. 177 

than one year, is usually insisted on, and this followed 
with the so-called mixed treatment (mist, biniodid. or 
its equivalent) for from one to two years longer: the 
same course also insisted on, no matter how late in the 
actual period the treatment is begun. The practice in 
Great Britain is, I believe, much the same. M. Fqurnier, 
who is the leading authority in France to-day, insists upon 
the same but a longer treatment. Four years he puts 
down as the minimum. He says (page 102) : " Three to 
four years — such is, according to my view, the MINIMUM 
[note well the word if you please], the indispensable 
minimum, in order that the diathesis may sufficiently 
disappear, under the double influence of time and treat- 
ment, and that the patient, returning to a healthy posi- 
tion, may have the right to aspire to the titles of husband, 
father, and head of a family." 

M. Fournier is somewhat peculiar in his mode of ad- 
ministration of the mercurial: proceeding by periods 
of activity and repose — giving it for a month or two, 
and then omitting for about the same period. It will 
thus be seen, that, practically, he administers little if 
any more of the mercurial, than we, who administer the 
drug at the point of easy toleration, throughout the 
whole of the active period. For the settlement of ques- 
tions so important as those which have been briefly 
touched upon in the foregoing pages, it is essential that 
those especially interested in, and familiar with, syphilis 
in its various forms, in its relation to scientific medi- 
cine and to humanity, should record with scrupulous 
care all unquestionable facts, concerning the duration of 
syphilis as an active contagious disease. That cases, 
proving disputed points or disproving them, should, 
when thoroughly satisfied with their value and suscepti- 
bility of proof, be forwarded to some convenient medical 
journal. Let an invitation be extended to those interested, 
to add a case in point, an opinion, or an analysis which 
might tend to strengthen facts, or expose errors of diag- 
nosis, or imperfect observation.. In this way, I believe, 
it need not be very long, before the great questions as 
to the duration of the period of possible communication 
of syphilis, would be narrowed down to such a point, at 



1^8 PRACTICAL CLINICAL LESSONS ON 

least, that the subject of syphilis, might, within a reason- 
able number of years — say three or four, or even five — at 
least, resume his ordinary association with his kind, 
without the ever-present dread of communicating syphi- 
lis, from an ever possibly recurring, periodically active, 
mucous patch. Prolonged existence of the contagious 
element in the seminal fluid, though a series of years, 
has been claimed, and instances have been cited, with 
great appearance of truth. M. Fournier quotes one re- 
lated by M. Jonathan Hutchinson : " Thus a medical 
man contracted syphilis and for about six months treated 
himself. Believing himself cured and being relieved of 
all pain, three or four years later he married. His wife 
remained healthy, and became enciente eleven times. 
First pregnancy, child born dead ; second pregnancy, 
child born dead ; third pregnancy, child born alive, but 
syphilitic, and dying with the usual symptons of here- 
ditary syphilis ; fourth pregnancy, child born living, but 
syphilitic and dying also with syphilis. On the con- 
trary, the seven last children, although born syphilitic, 
resisted the disease and lived." 

Here is a case of a healthy woman, giving birth to a 
series of children claimed to be syphilitic. In order to 
make this case of value, the evidence must be fuller and 
more explicit. The simple death of the child, is not 
sufficient evidence of syphilis ; repeated miscarriages 
are not necessarily from syphilitic influence; and incase 
of the third and fourth children, we are not informed as 
to exactly what constituted the evidences of hereditary 
syphilis. Various forms of imperfect development, and 
apparent disease of the foetus, result from scrofulous taint r 
from hereditary diseases not syphilitic, and from disease 
of and impressions on the female generative organs, and 
these propagated through successive pregnancies. Erup- 
tions, termed scrofidides, occur in the newly -born that 
are, sometimes, absolutely identical in appearance with 
those of syphilis. Cases of the character of the fore- 
going, may be true as far as the attainable evidence goes, 
but they must remain as doubtful, when the history is 
imperfect — because they are opposed to 'all that is 
known, with any certainty, of the nature of the disease. 



SYPHILIS AND THE GENITOURINARY DISEASES. 179 

The man, after four or five years, with no appreciable 
disease, infects children, while the mother remains healthy. 
According to the results of M. Mireur's experiments in 
inoculating healthy subjects, with the semen of syphilitic 
men, in the active stage of the disease, the semen does 
not possess the contagious property. M. Fournier says, 
(" Syphilis et Mariage," p. 26, note) : 

" It has long since been established that the semen of a 
syphilitic subject is not susceptible of transmitting contagion." 
If this be the fact, how, then, could the children be con- 
taminated by the husband, independently of any disease 
of the wife — who, it is claimed, remained healthy ? It is 
certainly the fact, that, with the exception of some rare 
and anomalous cases (such as the one quoted), the weight 
of the evidence of every authority has been given, in 
favor of a gradual diminution of the contagious element 
in syphilis, and its complete disappearance within three 
or four years. Under the influence of the old views 
that the later lesions — the sequelae — were also capable of 
transmitting syphilis, it was difficult to set a limit to 
the time, when a man could be said to be free from dan- 
ger of communicating the disease, but as it has now been 
satisfactorily proved, that the active stage of the disease, 
does not as a rule exist more than three or four years, 
and that the secretions of the sequelae and the blood are 
free from the contagious element, apparent exceptions to 
this law must be accepted as proved, only after the most 
rigid scrutiny, and refused admission, except on absolute 
proof. 

Note. — In the spring of i860, and thus over twenty 
years ago, I was called to see an infant about a year 
old, the daughter of a prominent merchant, a most up- 
right and religious man. The child had been vaccinated 
some three months previously without any unusual local 
result. About a month afterward a rose-colored erup- 
tion made its appearance, and, while fading somewhat, it 
remained, and began to create some apprehension lest 
it had resulted from an impure vaccine virus. When 1 
saw the child, the eruption was exactly like that of a fad- 
ing syphilitic roseola, slightly red, and inclining to a cop- 
pery hue, chiefly well-marked on forehead and cheeks- 



l8o PRACTICAL CLINICAL LESSONS ON 

breast back and abdomen. The date of its appearance, 
following vaccination, suggested syphilis, also its color, 
first rosy, then inclining to a coppery hue. I communi- 
cated my suspicion to the father and at the same time 
inquired into his venereal antecedents. He acknowl- 
edged to a gonorrhoea in early youth, which had caused 
him much remorse, but he denied knowledge of any syph- 
ilitic lesion. The wife was apparently in good health. 
There were three healthy children older than the little 
girl. The physician who performed the vaccination, 
stated its source, which was unobjectionable, and stated, 
also, that he had vaccinated at least a dozen children 
with the same virus as that used on this little patient, 
without an) 7 sign of such trouble following. Having 
scarcely a doubt of the syphilitic character of the erup- 
tion, I put the child on a systematic mercurial treatment ; 
this was continued for six months, without any especial 
change. I then called in the late Dr. Bumstead, (my 
predecessor in the Chair of Venereal Diseases in the Col- 
lege of Physicians and Surgeons, N. Y.) in consultation. 
My previous diagnosis was confirmed, unhesitatingly, 
and, for another six months, the same treatment was con- 
tinued. Not yet making any impression on the eruption 
— the child otherwise in excellent condition — Dr. Wm. H. 
Draper, who then occupied the Chair of Cutaneous Dis- 
eases in the College of Physicians and Surgeons, was then 
called in consultation. The case was accepted as most 
singular, but previous diagnosis, after careful considera- 
tion, was again confirmed, and, for another six months, the 
treatment was rigidly enforced, at the end of which time 
I took the responsibility of stopping the mercurial, as, up 
to that time, apparently, no benefit had accrued from its 
use. I then tried a mild arsenical preparation for a few 
months, with equal ill success,the eruption still remaining 
distinct and coppery in all regions previously occupied 
by it. During the next ten years the child grew fairly 
well. She was somewhat delicate, and of a nervous, lym- 
phatic temperament, and occasionally received a little 
aid to her nutrition, such as might be afforded by extract 
of malt, cod liver oil, etc. My attention at this time 
(when the child was now over twelve years of age) was 



SYPHILIS AND THE GENITO-URINARY DISEASES. l8l 

called to several exostoses on the radius and ulna, both 
at the distal and proximal extremites on the inner aspect, 
also on the outer and inner sides of the head of the tibiae. 
This seemed to confirm the original diagnosis, which I 
had long previously abandoned. I was contemplating 
a renewal of the treatment, adapted to the later stage of 
syphilis, when it occured to me to call in Dr. A. Jacobi, 
then Professor of the Diseases of Children of the College 
of Physicians and Surgeons. The eruption was some- 
what faded, but still distinct, on the cheeks, forehead, and 
breast, especially well-marked during any excitement, 
mental or physical. Professor Jacobi expressed an 
opinion against the idea of syphilis, and considered the 
eruption a scrofulide, and the exostoses rachitic. This 
fully explained the anomalous case of syphilis, as it had 
been supposed to be, and was then accepted, as rachitic, 
and was subsequently treated by me, in accordance with 
this view. The family leaving New York, soon after 
went to reside in -a neighboring city. Here, after con- 
sultation with the new family physician, the patient 
underwent another course of mercury, and this time 
with iodide of potassium for many months, and finally, 
having about a year since become quite lame from 
the growth of the extoses, and their interference with 
muscular action, a distinguished surgeon from New 
York was called in consultation, to see if any sur- 
gical aid could be afforded. A brother of the patient 
called on me a few months since to say that my old 
view of the case had turned out to be correct, and that 
no surgical aid was thought advisable, but the young 
lady had been put on a thorough course of mercury and the 
iodide of potassium." During the several years which had 
intervened, since the case had been previously con- 
sidered one of syphilis, the change of opinion had been 
lost sight of. Meeting the surgeon soon after his 
examination of the case, I recited the patient's former 
history which had not been made at all clear in the later 
consultations ; since this time I have had reason to be- 
lieve that the anti-syphilitic treatment has been again 
suspended. 

The father of the young lady whose history has been 



182 PRACTICAL CLINICAL LESSONS ON 

given above — after apparent proof that the vaccination 
was not at fault — became morbidly remorseful on ac- 
count of his early gonorrhoea. The later consultations 
were influenced, by a statement of the sons, that their 
father, just before his death, some years before, had given 
them to understand, that he had transmitted the disease 
to their sister through a youthful folly. 

It may be safely stated that the diagnosis of syphilis has 
often been made, on .much more slender ground than in 
the foregoing case, and the source of infection accepted, 
not because there was any reasonable proof, but because 
it was not positively accounted for in any other way. 
The mere suspicion of an attack of syphilis in a man's 
youth, in the minds of many physicians, appears to war- 
rant the assumption of an ever-present contagious ele- 
ment, and to account for any and every obscure trouble, 
which may afflict himself, his wife, or his children, to 
the end of life. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 1 83 



LESSON XIX. 

GUMMY TUMOR OF BONE — LOSS OF SUBSTANCE WITH- 
OUT CARIES. 

Clinical case in illustration. Facts showing that the disease is local in 
its nature. The dry caries of Virchow due v like all tertiary lesions of 
syphilis, to mechanical causes. No contagium ever discovered in them. 
Lesions like those in case cited due to pressure from accumulation of 
lymphatic material. Similarity between the behavior of so-called dry 
caries and the tubercular syphilide. Van Buren and Keyes's explana- 
tion of the latter. Clinical case illustrative of the lesion termed Syph- 
ilitic Dactylitis. Behavior of this lesion shown to be identical with 
that of the so-called dry caries, and due to similar causes. 

Case VII. B. W. F. ; aged 70; merchant. General 
health always good. Came complaining of the annoy- 
ance caused by two painless ulcers, about the size of 
a quarter-dollar, just above each frontal prominence. 
The edges were abrupt and sharp ; the entire integument 
was penetrated, and the floor of the ulcers was covered 
with large florid granulations. These lesions were said 
to have appeared about six months previously, very soon 
attaining their present dimensions, and continuing quite 
stationary, in spite of many sorts of local application 
recommended by the family physician. As the patient's 
general health was perfect, no internal treatment had 
been resorted to. The gentleman was quite bald, and on 
examination, several depressed portions of the scalp 
were recognized, of about the same dimensions as the 
ulcers. It was evident, to the touch, that there had 
been a distinct sinking of the bone. This was uniform 
and to the depth of about one line; the scalp was 
smooth and movable at these points. In point of fact, 
the evidence of a former, so-called, dry caries, was in- 
contestable. All had occurred within the year, or rather 
they had only attracted attention during that time. 
Throughout their course were not recognizable by the 
patient, from any discomfort or sensation of any sort 
experienced by him. A course of potass, iodide and 
biniodid. hyd. (mist, biniodid. hydrarg.) was prescribed, 



1 84 PRACTICAL CLINICAL LESSONS ON 

under which, within the following month, the sores 
healed perfectly, with a firm cicatrix, scarcely at all 
depressed. 

Remarks. — The foregoing case has an special value, 
in the fact, that the bone lesion, the " dry caries" of 
Virchow, is specific ; that is to say, it is seen only as a 
sequel of syphilis, and is reliably diagnostic of that 
disease. Furthermore, it enables us to understand, 
better than any other sequel of syphilis, that the pro- 
cesses which result in destruction of tissue, of every 
variety of tertiary lesion or sequelae, are not due to any 
destructive principle, or virus, circulating in the blood, 
but are due to mechanical obstructions of lymph vesr 
sels, through damage to such vessels or channels, during 
the early active stages of the disease. It is conceded 
by all scientific authority, that the late lesions, the seque- 
lae of syphilis, without exception, are characterized by 
a localized accumulation of the so-called gummy mate^ 
rial. It is found in every so-called tertiary lesion, and 
in amount, sufficient to account for the damage associ- 
ated with it, on purely mechanical principles. Pressure 
on vessels of nutrition results in loss of tissue through 
fatty degeneration, locally and in the parts distant, to 
which such vessels are distributed, obstruction of the 
adventitia of blood-vessels, resulting in pressure upon 
such vessels, is recognized as a cause of obliteration of 
their lumen. This gummy material has been proved 
not to differ, in the least degree, from accumulated 
normal lymphatic material. No contagium of syph- 
ilis has ever been detected in it. In the tubercular 
eruption this accumulation of gummous material, so 
called, is often absorbed, leaving cicatricial depres- 
sions, which are characteristic, without suppuration. 
It is recognized as resulting from pressure upon the 
tissue into which it is infiltrated, or in which it accu- 
mulates, causing absorption of the tissue. When the 
gummy material is taken up, the cicatricial depres- 
sions result* Applying the same explanation to lesions 

* " The syphilitic tubercle is due to a diffuse hyperplasia of small 
cells in the substance of the true skin. These cells, which partake of the 
nature of the so-called gummy exudation, grow at the expense of the 



SYPHILIS AND THE GENITO-URINARY DISEASES. 1 85 

of bone, like those designated the dry caries of syphilis, it 
will be seen that gummy accumulations in bone may 
follow the same course, and that the so-called dry caries 
is not a true caries at all, for there can never be caries 
without suppuration. The fact becomes evident, that 
the loss of bony material, which results in the depres- 
sion, is caused through absorption of the bony material 
through pressure by the accumulated gummy deposit. 
Not producing suppuration or caries, but, by pressure, 
causing absorption of the bony structure without in- 
flammation, without suppuration, without caries. In 
this way, and in this way alone, can cases of so-called 
dry caries, initiated without inflammation, progressing 
to well-recognized loss of bone structure, without sup- 
puration, or caries, be satisfactorily accounted for. 

SYPHILITIC DACTYLITIS. 

G. B. W., printer, 45 years old ; tall, delicate ; has 
never been strong; supposed himself of scrofulous 
diathesis, as his mother was affected with a "salt 
rheum." In i860 had an injury of the left leg which 
developed an indolent ulcer. From long-standing at his 
business this continued open, during six years, and was 
known, and treated from time to time, as the "printer's 
sore leg." Became an editor, and thus, relieved from 
necessity of standing, the ulcer healed. After this, 
occasionally took sarsaparilla, iodide of potass., etc., for 
his supposed scrofulous diathesis. Remembers to have 
had dull pains in his muscles, and also in bones : had 
also slight pain in fingers of right hand. These pains 
were relieved by application of tr. of iodine. Never 
had any evidence of an initial lesion of syphilis, or any 

natural tissues, and cause the atrophy of more or less of the substance of 
the latter, even while there is apparently a hypertrophy, as evidenced 
by the little tumor called a tubercle. When, however, the adventitious 
newly formed cells go into atrophy, and are absorbed during the pro- 
gress of the eruptions, then, not only does the tubercular prominence 
disappear, but the scar left attests the atrophy and absorption of the true 
elements of the skin tissue, which took place during the deposit of the 
morbid material." — Van Buren and Keyes on " Genito-Urinary Diseases 
with Syphilis," p. 583. D. Appleton & Co., New York, 1874. 



186 PRACTICAL CLINICAL LESSONS ON 

sore on any part of his body which was suspected to be 
such. Pain in his fingers first noticed about two years 
ago. Injured his fingers slightly, and swelling began. 
This was treated by local application of tr. iodine, but it 
continued, and after a few months the finger became 
distorted in shape, and appeared shorter than before. 
Middle finger of opposite hand then began to swell, 
like the first, without special pain. Physicians who ex- 
amined him, attributed his difficulties to scrofula, and 
for several months he took hydriodic acid, cod-liver oil, 
etc. General health much improved but local trouble 
remained. Careful questioning failed to elicit evidence 
of any lesion of acute syphilis. A deeply copper-colored 
scar was found on the site of the chronic ulcer of the 
leg, previously described. The middle finger of either 
hand was swollen at the second joint. That of the 
right hand was slightly bent towards the forefinger, and 
shorter than the left by fully half an inch ; slight crepita- 
tion and slight tenderness on pressure; increased mobil- 
ity at the joint, which was evidently due to loss of bony 
tissue, chiefly in the distal end of the second phalanx. 
The second joint of the middle finger of the left hand 
was swollen, slightly sensitive on pressure; this trouble 
was comparatively recent, having occurred within 
three or four months. The characteristics of the bony 
lesions in this case were distinctly those of dactylitis 
syphilitica, and yet there was no syphilitic history to be 
obtained. The patient then remarked that he had a 
small sore on his back, which had been bothering him 
slightly, for several weeks. Examination showed a 
sharply cut ulceration, about the size of a silver half- 
dollar, extending through the thickness of the skin, per- 
fectly characteristic of a late syphilitic ulcer, due to 
breaking down of a gummy infiltration or accumu- 
lation. This settled the diagnosis beyond a question, 
and the patient was at once put upon an anti-syphilitic 
treatment. Iodide of potassium in even three or four 
grain doses caused gastric irritability. Iodoform, which 
had been previously well borne, was resumed, I gr. 
(Warner's pills) thrice daily, and \ gr. of the protoiodide 
of mercury; also mercurial fumigations, twice week- 



SYPHILIS AND THE GENITO-URINARY DISEASES. 1 87 

ly. This was continued for a month, with some appre- 
ciable benefit, and especially to the sore on the back. 
This, treated locally with iodoform, had entirely 
healed, when the patient began to complain of tender- 
ness of his gums. Fumigations were omitted. The 
patient was not seen again until March 3, 1883. The 
pills of iodoform and proto-iodide of mercury had then 
been taken, twice daily (a third pill always causing 
digestive discomfort), for fully fifteen months. The 
second joint of the right middle finger, previously 
affected, was now apparently normal in every respect. 
That of the right, was free from tenderness, or any sign 
of inflammatory trouble, and was also reduced in size. 
The mobility was much increased. The first and 
second phalanges appeared atrophied and shortened as 
in the accompanying sketch. There was no longer any 
evidence of present diseased action, and discontinuance 
of specific treatment was advised. 

Remarks. — Noth withstanding the failure to obtain any 
proof of acquirement of syphilis in this case, the pecu- 
liar history, appearance, and nature of the deformity of 
the fingers, made its syphilitic origin almost a certainty. 
The presence of a characteristic late syphilitic ulcer 
set the question, if one could have been raised, per- 
fectly at rest. Ordinarily, a full course of treatment 
suitable for late syphilitic lesions, viz., small doses of 
mercury and gradually increasing doses of iodide of 
potassium would have been employed, but the idiosyn- 
cracy of the patient prevented. And yet under the 
mild continuous use of iodoform and proto-iodide of 
mercury the case went on without discomfort, to com- 
plete recovery in the right, and the same (leaving only 
deformity from previous bony loss) in the left. 

The nature of the lesion in this case, is almost, if not 
precisely, identical with that of the former one, in which 
the so-called dry caries — loss of bone without necrosis — 
was present. It has been shown to be due to accumula- 
tions of germinal material (gummy deposits) in and 
around the joints. Absorption of bony material causes 
the final deformity, and this is brought about by press- 
ure from purely mechanical conditions. A full and most 



1 88 PRACTICAL CLINICAL LESSONS ON 

admirable account of dactylitis syphilitica may be 
found in Bumstead & Taylor on Venereal Diseases, 
(Phila., 1879,) P- 671, ct sea. On p. 675 the}' remark: 
" These bony swellings may remain in an indolent con- 
dition for along time, and finally the gummy deposit 
may be absorbed, or it may soften and be discharged 
through asinus. . . . The absorption of the bone is unac- 
companied by ulceration of the soft parts " (p. 576). 

In the excellent work on Genito-Urinary Diseases 
with Syphilis, by Van Buren & Keyes, (N. Y., 1874.) page 
625, they say of such cases: "Appearances similar to 
those found in dry caries have been encountered in the 
affected phalanges after death. The gummy deposit, 
after producing great swelling of bone by its infiltra- 
tion, undergoes absorption without ulceration, as in dry 
caries, and results in loss of substance of the bone, 
which is not replaced by new tissue. If very rapidly 
formed, the gummy deposit may undoubtedly break 
down and be eliminated externally." 

It is immaterial in regard to treatment, whether the 
so-called gummy deposit is in the bone structure, in the 
fibrous or cartilagenous structures, or in the adjacent 
soft parts : wherever it is imprisoned, so as to produce 
mechanical pressure, the parts must yield sooner or 
later, either slowly, through absorption, or setting up 
an inflammatory process, more or less acute, cause 
death of tissue. The same behavior of the so-called 
gummy material will be recognized in every kind of 
late or tertiary lesion (syphilitic sequelae), viz., absorp- 
tion of unyielding surrounding structures from mech- 
anical pressure, or inflammation and suppuration necro- 
sis through direct mechanical injury, or indirectly 
through destruction or impairment of vessels of nutri- 
tion. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 1 89 



LESSON XX. 

SYPHILITIC SEQUELS INVOLVING NASAL BONES, VOMER 
AND VAULT OF THE HARD PALATE. 

Clinical case in illustration. Treatment by internal remedies. Slow 
progress through this agency. Final cure without deformity. Second 
case treated by mechanical removal of necrosed bone. Operated on 
through nasal orifices by means of the dental engine. Prompt re- 
covery. Syphilitic necrosis a local disease. Early removal of dead 
bone advisable. Recovery usually as prompt as when the disease re- 
sults from other causes than syphilis. 

B. W.; 37. Syphilitic history : active stage three years 
previous ; irregularly treated for about a year, during 
which he had a sparse papular eruption lasting a couple 
of months, also ulcers in the mouth and throat at the 
same time. Since then, had no evidence of syphilitic 
trouble, until about three months previous, when he be- 
gan to have slight pain in his nose with some nasal 
catarrh. This continued to annoy him, the discharge 
increasing, and finally tinged with blood, and at times 
quite foetid ; tenderness over the nasal bones also in- 
creased, and a redness appeared, with increased soreness. 
Had been under care of physician, who gave him 
internally some iodide of potassium, and a wash to use. 
This dissipated the odor, but the soreness increasing 
he concluded to seek other aid. Examination showed 
the nostrils filled with hard black scabs ; odor foetid. 
Probe introduced strikes loose bone; a flat ragged 
piece about the size of a half-dime removed ; quite ex- 
tensive surface of dead bone recognized, but no more 
could be removed. Patient put upon mist, biniodid., 1 
teaspoonful thrice daily. Besides this, iodid. of potass., 
increasing one grain at each dose up to sixty, largely 
diluted with milk ; permanganate of potassium, two 
grains to water an ounce, to be used through a syringe in 
cleansing and deodorizing the parts. Subsequently, sev- 
eral pieces of turbinated bone came away and also several 
pieces of the nasal bones. As soon as any portion was 
found loose it was carefully eliminated ; medicines faith- 



I90 PRACTICAL CLINICAL LESSONS ON 

fully used ; potass, iodid. up to 3 i. three times a day, 
but it was nearly three months before the necrosed bone 
ceased to separate, and the discharge to lose its charac- 
teristic fcetor, and finally to cease. Fortunately, the 
destruction was not sufficient to produce any external 
deformity, and the case was claimed as showing pecu- 
liarly satisfactory results of treatment. 

Case II. W. G. H.; aged 17. History of active 
syphilis, under care of Dr. Leving, of London. A lit- 
tle over two years, after began to suffer with foetid 
nasal catarrh. Was said to have been treated by Mr. 
Walter Coulson, of London, with iodide of potass., etc.; 
Trouble continued increasing, when he presented to me 
early in Jan., 1880. Necrosis extensive and was evidently 
progressing ; discharge profuse ; odor foetid. Probe 
touched dead bone at several points, and some small 
pieces of the vomer were removed. Tissues cover- 
ing arch of hard palate, red and tender. Patient 
put upon full course of biniodid. with increasing doses 
of iodid. potass. In the course of a few days the in- 
flammation of tissues covering hard palate increasing, 
a perforation ensued. This affected patient's voice un- 
pleasantly, and as he was a public singer, he was 
greatly disturbed, and begged for some more effi- 
cient mode of relief. Instead of encouraging him to 
wait, under an efficient specific treatment, until the slow 
separation of the necrosed bone was effected, I sent 
him to Dr. J. H. Goodwillie, whose demonstrations in 
removal of necrosed bone by aid of the dental engine I 
had witnessed on several occasions, and who subsequent- 
ly published an account of the case at my request, and 
has sent me a copy for insertion in this place. Of the 
condition of the patient, Dr. G. says : 

" He now has necrosis of the vomer and vault of the 
palate, with a small hole in the latter. Foetid discharge 
from the nose, occasionally stained with blood from ex- 
cessive granulations. Administered iodide of potassium 
and cod-liver oil. Local treatment consisted in blowing 
into the nasal cavities iodoform and camphor triturated 
to an impalpable powder, with subnitrate of bismuth 



SYPHILIS AND THE GENITO-URINARY DISEASES. IQF 

and sulphate of potash, to reduce the superabundant 
granulations, and so have less bleeding during the 
operation. By invitation of the late Professor James 
R. Wood, M.D., to deliver a clinical lecture on extirpa- 
tion of bones of the mouth and nose, I operated on this 
patient at his clinic at Bellevue Hospital, January 15, 
1880. Administered four ounces of whiskey before the 
operation, and kept him under the influence of nitrous 
oxide during the operation, which lasted about fifteen 
minutes. No external incision was made, and the 
necrosed vomer lower portion of the ethmoid, both in- 
ferior turbinated bones and vault of the hard palate, 
were removed, by the revolving knives, through the 
nostrils. 

No portion of the s v oft tissue on the hard palate was 
removed. On the completion of the operation, he was 
directed to blow his nose, to free his nasal cavity of the 
cut-up necrosed bones and blood, and then he was posi- 
tively forbidden to again blow his nose, for the next 
twenty-four hours. After that time, the clotted blood 
was carefully removed by the dressing nasal forceps, and 
the nasal cavity completely covered by blowing in the 
iodoform and camphor powder. 

" On the second day a nasal douche was given before 
the application of powder. 

" On the next day after the operation he was able to 
attend to his daily duties. 

"The wax model illustrating his case shows the open- 
ing in the palate one-fourth inch in length before the 
operation. Atrophy of the nose before the operation, 
from the non-respiration and constant blowing of the 
nose, as seen in the right ala, and the development of 
the ala, as seen in the left side of the nose, after the 
operation. 

" The other model shows the opening in the palate 
closed and a new deposit of bone over the palate. 

" He is in perfect health at the present time." 

In syphilitic caries involving the vomer, the nasal 
and turbinated bones, and contiguous bony structures 
difficult of access to ordinary surgical proceedure, the 
removal of diseased bone requires especial instruments 



I92 PRACTICAL CLINICAL LESSONS ON 

and skill not within the reach of the ordinary surgeon. 
The dental engine affords access to such necrotic pro- 
cesses, and until the surgeon can personally avail him- 
self of the facilities it affords, for removal of carious 
bones in such situations, it is my opinion, that the 
best course will be, to relegate cases of this nature, 
to men who, like Dr. Goodwillie, have the mechani- 
cal skill and experience in the use of the dental en- 
gine requisite to perform the operations necessary for 
the complete removal of diseased bone in these locali- 
ties. Otherwise we must usually follow the old plan of 
waiting, until the separation occurs, through the tedious 
process of exfoliation, aided by such internal remedies 
as have heretofore been relied upon for the care of 
these cases. This involves the danger of deformity, 
and delay in cure, which it seems to me few surgeons, 
aware of what especial skill in the management of the 
dental engine can accomplish, will feel inclined to ac- 
cept. My own experience in several cases of syphilitic 
caries of the bones of the skull, where I had operated 
for removal of the diseased bone, and found rapid recov- 
ery result, has convinced me that, when syphilitic 
necrosis occurs, it is a purely local matter, and that it 
is good practice, in all such accidents, to remove the 
dead bone at the earliest practicable period, and that, as 
a rule, to \vhich there are few exceptions, such removal 
will result in as prompt recovery as when the necrosis 
has occurred from other causes than syphilis. 



SYPHILIS AND THE GENITOURINARY DISEASES. 193 



LESSON XXI. 

GUMMY TUMOR OF BONE — PRODUCING BRAIN SYMP- 
TOMS, ETC. 

Clinical case in illustration. Such lesions of rare occurrence before the 
second or third year of syphilis. Insidious in access. Sometimes pro- 
ducing extensive loss of bony tissue. First signs often through oc- 
currence of vertigo, epilepsy, aphasia, or paralysis. Same symptoms 
may occur from accidents of the acute stage of syphilis. Cases in illus- 
tration. Possibility of confounding the brain and nerve disturbances 
of late syphilis, with those due to processes of the active stage of the 
disease. Mauriac's views in support of this position. Cornil's views. 

Case VIII. L. G., 35 ; policeman. In good general 
health. Had a history of irregularly treated syphilis, 
twelve years previous. About five years ago, he first 
noticed a swelling on the top of his head ; also soon 
after, another on the left side: not tender, causing no 
inconvenience or pain. About a month after, he re- 
ceived a blow on tumor No. 1, after which he had 
much pain, and it finally suppurated and discharged 
pus freely. Examination showed an ulcer, about an 
inch in diameter, perforating the scalp just anterior to 
the vertex. The probe touched bony material at once, 
and a loose piece, half an inch square, was readily ex- 
tracted. The second and more recent swelling was 
about the size of half a pullet's egg, very hard and in- 
sensitive. The man was at once put upon a mixture of 
biniodide of mercury and iodide of potassium, the latter 
in increasing doses. 

The open lesion, which was at first quite painful, soon 
became less so, and the iodide, at the end of a month, 
had been raised to seventy grains three times a day, in 
a tumbler of milk, and was well borne. Within three 
months (notwithstanding several intervals of two or 
three days each, when he was prevented from taking 
his medicine) the hard tumor had entirely disappeared. 
His only complaint was of occasional vertigo. This 
continued after the healing of the necrosed lesion, which 
occurred a month or two later, leaving a cicatricial de- 



194 PRACTICAL CLINICAL LESSONS ON 

pression which indicated loss, through to the inner table 
of the skull. The vertigo, which appeared to be symp- 
tomatic of a bony growth on the inner surface of the 
cranium, after some four months more of treatment 
finally disappeared. He was, however, kept on the sim- 
ple mist, biniodid., a drachm thrice daily for the follow- 
ing year, and he has*had immunity from trouble for the 
past three years. 

Remarks. — Tumors of the cranium rarely occur be- 
fore the second or third year of syphilis, and more 
often, not before the twentieth or later. Their access 
is very insidious, and as they are usually without pain, 
often come to considerable size before discovery. If 
the patient is temperate, and in good general health, 
they may remain stationary, at any point, without appar- 
ent change, until some irregularity in living or depres- 
sion of the vital powers, disease, or injury as from a 
blow, when they inflame and break down, leaving a 
bony ulcer involving the thickness of the external table 
and the diploe. Penetration of the internal table is rare. 
The extent to which the skull may be damaged in this 
way is scarcely conceivable. The same mode of impli- 
cation may extend even beyond its parictes to the 
bones of the face. The first announcement of trouble, 
in cases of cranial syphilis, may be through the occur- 
rence of some nervous trouble from pressure on the 
brain ; vertigo, as in the case just cited ; epilepsy, aphasia, 
or muscular paralysis. The reasonable suspicion of 
antecedent syphilis, should be the signal for prompt and 
efficient treatment, addressed to the removal of syphilitic 
sequelae. Brcin and nerve disturbance occurring during 
active stage of syphilis, during the early months of syph- 
ilis, i.e., in the acute or secondary stage, localized para- 
lysis or acute brain disturbance may occur — not due to 
the accumulation of the so-called gummy material,which 
does not exist during the active stage, but from the pres- 
sure caused through the formation of an accidental pap- 
ule, or its equivalent, within the skull, or in the track or 
sheath of a nerve. Quite recently I have seen a facial para- 
lysis extending to the hand of that side, in the papular 
stage of syphilis, passing off under treatment, simul- 



SYPHILIS AND THE GENITOURINARY DISEASES. 19$ 

taneously with the other lesions of that stage. Within 
the last three months a young gentleman under my care 
in the fifth month of syphilis,with papules, though sparse, 
yet distinct and characteristic, was suddenly attacked 
with acute mania. Two distinguished alienists of this 
city who were called in, pronounced the case one of 
commencing paresis, and sent the young man to Bloom- 
ingdale Asylum. In the course of a few weeks he was 
sufficiently recovered to be able to signify to his medi- 
cal attendant at the asylum, that he was under treatment 
for syphilis when attacked with his mania, and showed 
the stains left by the papules. The result was a re- 
sumption of treatment for syphilis and complete recov- 
ery, within a very short time, when he voluntarily re- 
turned to my care. 

The possible error of mistaking conditions, like the 
foregoing, for late accidents of syphilis, will be apparent.* 

Syphilitic ostitis and periostitis, osteophytes, exostosis, 
epiphysial and parenchymatous, enostoses eburnation of 
bone, etc., of the active period oi syphilis may be, I think, 
legitimately claimed to result from one and the same 
cause, viz., the cell aggregation and proliferation, in 
loco, which when occurring in the integument constitutes 
the papule. 

This view would rationally explain the position of 
M. Mauriac, recently quoted in the American edition of 
Cornil on Syphilis, and which thus considered, is so 
entirely in harmony with my own position, that I shall 
yield to the temptation to quote some of M. Mauriac's 
statements bearing on this point. He says : f 

(1) " Pericranial periostitis is often among the early 
manifestations of syphilis . . . even before the secon- 
dary lesions. 

(a) "It is seated exclusively in the periosteum of the 

* An accidental papule sometimes may be seen developing in the an- 
terior chamber of the eye during the active stage of syphilis, which has 
received the title of gummy tumor of the iris. This apparent misnomer is 
calculated to create the impression that gummy tumors do sometimes 
occur during the early months of syphilis, I think, which can be satis- 
factorily" proven to be an error. 

f Cornil on Syphilis, Am. ed., 1S82, page 264. 



I$6 PRACTICAL CLINICAL LESSONS ON 

cranium, and if hyperasmia or inflammatory lesion of 
the osseous tissue exists it is secondary and remains 
subordinate to the periostitis. 

(b) " Pericranial periostitis is the result of a true in- 
flammatory process — an irritation or active process, as 
indicated by its acute symptoms and active course. 

(The same may be said of the initial lesion of syphilis, 
or the papular eruption, both of which have been shown 
to produce irritation, through mechanical obstruction 
to the processes of nutrition rather than from the inflam- 
matory nature of the lesions.) He further says : 

(c) " This variety of cranial tumors, when a result of 
acquired syphilis in the adult, has a tendency to resolu- 
tion, eitJier spontaneously or by appropriate treatment. 
The swelling readily disappears without leaving any 
trace. 

(Italics my own, to indicate the exact correspondence 
of these tumors in their behavior with that of the pap- 
ular eruption.) 

(/) " The tumors may be discrete or confluent, and 
usually are located on the anterior half of the cranium. 
Their duration varies from four to six weeks when not 
submitted to treatment. Under proper medication they dis- 
appear sooner. 

(2) " Periostitis of the ribs, costal cartilages, and ster- 
num may occur at the beginning of syphilis. 

(3) " Periostoses and exostoses may develop at other 
parts of the osseous system during the early period of 
constitutional syphilis. 

(a) " The period of incubation of these osseous lesions, 
dating from the appearance of the chancre, varies from 
thirty to one hundred and twenty days. 

(b) " They may appear several days before eruption 
of the secondary cutaneous or mucous lesions. They 
occur spontaneously without the intervention of any 
exerting cause. 

(c) " They seem to result from a form of syphilitic in- 
fection, in which the virus is unusually active, as com- 
pared with the resistant powers of the organism con- 
taminated. 

(5 — a) " They may recover spontaneously, but they 



SYPHILIS AND THE GENITOURINARY DISEASES, igf 

disappear very much more rapidly under mercury and 
iodine, with local anti-phlogistic treatment. 

(b) "They complicate the prognosis of syphilis, al- 
though they are often associated only with mild lesions 
in other organs and do not necessarily indicate a malig- 
nant local process or serious general constitutional 
tendency." 

It appears to me to require a very moderate degree 
of perspicacity, to discover a remarkable similarity, in 
time, mode, and degree of development, in behavior 
after development, with and without treatment, and in 
relation to the prognosis of a given case, with that of 
the papular eruption. Considering, then, the power of 
penetrating through any and every tissue, occasionally 
manifested by the amoeboid cell, or syphilitic disease 
germ, the wonder only appears to be that such acci- 
dents as the local proliferation and accumulation of 
such cells, in various localities, outside their usual chan- 
nels, are not more frequently observed. The proba- 
bilities appear to me that such erratic accumulations 
do very often occur, in the way just mentioned, but, 
that, as they are most likely to be located in the softer 
tissues, the mechanical disturbance is not sufficient to 
attract attention ; but when occurring in the bony struc- 
tures, or between these and the periosteum, very natur- 
ally periostitis of the mild and transient character, de- 
scribed by Mauriac, would be likely to take place. It 
is also a significant fact that such proliferations are 
favored by a sluggish circulation, such as may be in- 
ferred, in cases as Mauriac says (3) " in which the virus 
is unusually active as compared with the resisting power of 
the organism contaminated." 

In connection with the statements of Mauriac and 
with the views just expressed, it will be interesting to 
recall what M. Cornil says as to the mode of origin of 
syphilitic osteo-periostitis. " Syphilitic periostitis does 
not differ materially from ordinary osteo-periostitis, 
limited to the superficial layer of the bone and the 
periosteum, it most frequently occurs at the end of the 
secondary or in the tertiary period, attacking the tibia, 
clavicle, sternum, bones of the head, etc. 



I98 PRACTICAL CLINICAL LESSONS ON 

" Beneath the periosteum, between it and the bone,, 
there collect numerous round cells , analogous to those of em- 
bryonal marrow. At the same time the deep layers of 
the periosteum are inflamed and contain cells interposed 
between the fasceculi of fibres. The neighboring connec- 
tive tissue of the periosteum, generally presents a slight 
inflammatory oedema, so that the tumor, situated be- 
tween the skin and bone, is due both to the swelling of 
the periosteum and to the inflammatory oedema of the 
subcutaneous connective tissue. The surface of the 
bone beneath the periosteum, has the openings of the 
Haversian canals enlarged and filled with marrow, 
which is either red and embryonal, or is gray and 
gelatinous, consisting of the round cells of the medulla. 
The fat has disappeared from these changed canals. 
This form of mild periostitis may disappear and leave no 
trace, even when it is quite deep, and in a flat bone, as 
the sternum ribs or cranium. It is accompanied with 
an embryonal condition of the marrow of the whole 
bone." (Cornil on Syphilis, Am. Ed., Henry C. Lea's 
Son & Co., Phila., 1882, pages 247, 248. 



SYPHILIS AND THE GENITO-URINARY DISEASES. I99 



LESSON XXII. 

LATE BRAIN LESIONS OF SYPHILIS — GUMMOUS INFIL- 
TRATION OF. 

Clinical case in illustration. Prompt beneficial effects of specific treat- 
ment. Large doses of iodide of potassium evidently beneficial. Prompt 
retrogression in patient's condition through their discontinuance. Re- 
newed improvement through resumption of remedies in mild form, 
and subsequent deterioration. Resumption of large doses of iodide of 
potassium objected to, and final relapse of the patient resulting in con- 
firmed dementia. Remarks. Mr. Hutchinson's views of the diseases 
of the brain due to syphilis. Correspondence of the same with condi- 
tions in foregoing case. Suggestions of treatment for similar cases. 
Iodide of potassium in large doses claimed to be essential in treatment 
of the sequelae of syphilis. This confirmed by experience of accepted 
authorities. 

W. S. S., 37 ; civil engineer. History of a mild form 
of syphilis at 24 ; indurated initial lesion ; sparse pap- 
ular ; syphilide ; partial alopecia; mucous patches in 
throat. Desultory treatment by mercurials for three 
or four months. No appreciable evidence of disease 
after the sixth month. 

Eleven years after, while in South America, engaged 
in very engrossing mercantile business, while in robust 
general health, he gradually became conscious of a fail- 
ing and uncertain memory. His partners had observed 
this previously. He became also unusually emotional ; 
tears coming without due occasion. He would drop 
asleep over his ordinary work, omit words in his busi- 
ness letters, recognizing this himself, on reperusal. He 
continued for two or three months to transact business, 
but was no longer trusted to do so without supervis- 
ion. His physicians pronounced his trouble acute- 
softening of the brain, and he was sent home. He 
came under my care in March, 1878. He was still in 
excellent health. In addition to the foregoing symp- 
toms, he had some aphasia and slowness of utterance ; 
he was no longer able to correct his written mistakes 
as before, but was able to give a connected account of 
his trouble and also of his previous syphilis. He had 



200 PRACTICAL CLINICAL LESSONS ON 

up to this time been treated, chiefly, by use of the 
bromides and strychnia, but had slowly, but steadily, 
deteriorated mentally, while his general health was yet 
perfect. He was an excessive smoker, and drank alco- 
holic beverages two or three times a day. 

Mr. J. was at once put on the mist, biniodid. hydrarg. 
a teaspoonful thrice daily, with the addition of one 
drop of a saturated solution of the iodide of potass, 
with each dose, in half a small tumbler of milk thrice 
daily. Smoking and spirituous liquors wholly inter- 
dicted — plain wholesome food, regular hours, took the 
place of ill-selected food and late hours. The solution 
of the iodide was increased by one drop for each dose 
of the mixture, and given separately from it in a half 
tumbler of milk, and this continued up to the tenth day, 
when he was taking 30 drops or 30 grains of the iodide 
of potass., besides the 8 grains in his biniodide mixture 
in which he got also y 1 ^ of a grain of the biniodide of 
mercury. Already there appeared some signs of amend- 
ment. The iodide was now increased more slowly : 
only one drop per day instead of one at each dose, as 
he complained of a little sense of nausea at times after 
taking the medicine. The milk was increased so that 
at the end of the third week from this he was taking 52 
grains in a tumbler of milk, besides his mixture, con- 
taining 8 grains more, making one full drachm of the 
iodide of potassium, and ^ of a grain of the biniodid. 
of mercury three times daily, and bearing it perfectly ; 
smoking but one cigar daily and drinking but claret 
with his dinner. He had now improved so much that 
his friends remarked it on meeting in the street. He 
was less somnolent, and his difficulty of utterance was 
scarcely noticeable, as he was naturally slow of speech. 
This treatment was continued without change in any 
particular for three months, with gradual improvement, 
when, notwithstanding several lapses in his abstinence 
— on one occasion dissipating for several days — he had so 
far recovered that he considered himself, and his friends 
considered him, quite well. His medicines were given, 
however, with the distinct understanding that unless 
some especial contra-indication occurred, they should be 



SYPHILIS AND THE GENITO-URINARY DISEASES. 201 

continued in same doses, viz., I drachm of potass, iodide, 
and -Jj hydrarg. biniodid. thrice daily for at least one year. 
Continuing apparently well for the next few months, he 
went to London, where he consulted an expert, who, 
while approving the previous treatment, thought it had 
been continued long enough and directed that it be dis- 
continued. At the end of a month the patient went to 
Paris, and after a short period of dissipation was seized 
with acute mania and was placed in a Maison de Sante, 
where he soon became aphasic and somnolent, and 
his case was accepted as one of acute idiopathic cere- 
bral ramollissement. A history of the case was sent 
to the physicians then in charge of the case, with 
suggestion to resume the former specific treatment. 
Under mercurial inunctions and small doses of potass, 
iodid. the patient once more improved, and hopes of 
complete recovery were held out. From being unable 
to recognize his relations, even requiring aid in all the 
operations of his excretory functions, and even sitting 
at times with open mouth and food unmasticated in it, 
he became able to help himself in all ways, to write 
legible and coherent sentences and dates, to recognize 
and converse intelligibly, though with thick and at 
times somewhat difficult utterance. At this time, being 
in Europe, I was desired to see him in consultation 
with the medical officers under whose care he was, and 
found him in the condition last above described. The 
former diagnosis of the syphilitic origin of the trouble 
was concurred in by the resident physician, but great 
surprise was expressed at the magnitude of the doses 
of iodid. of potass, which had been used. When their 
immediate resumption was urged, a deprecating shrug 
accompanied the consent given, and it seemed scarcely 
probable, although the recommendation was enforced 
by cases and authorities, that the patient would get the 
full measure of what was, evidently, considered heroic 
treatment. Within a few months he began to retro- 
grade ; had frequent epileptiform seizures, and now, 
after a year, is still under the same care, in a state of 
hopeless dementia. 



202 PRACTICAL CLINICAL LESSONS ON 

Remarks. — Mr. Hutchinson, of London,* in discuss- 
ing the diseased conditions of the brain due to syphilis, 
says, " If we say that we recognize three forms of 
cerebral disease — one in which the symptoms result from 
arterial occlusion, one from irritation of gummata, and 
one from periosteal thickening — we may assume that 
sudden attacks of paralysis denote one, that the second 
has all the symptoms common to cases of tumor, and 
that severe pain and headache go with the last. . . . No 
doubt in some cases all three lesions present together, 
and in many two of them." The probabilities seemed 
to me in favor of the accumulation of germinal material 
(gummy deposits) in the adventitia of arteries, as 
described by Heubnerf and by Edes, % sufficient to 
produce in the first instance symptoms of pressure, then 
of irritation, finally obstructed circulation and conse- 
quent softening. The two causes, viz., arterial occulu- 
sion and irritation and pressure from gummata, combin- 
ing in this case. The prompt benefit from specific 
treatment in the first instance warrants the belief that 
its continuance as originally contemplated would have 
not only prevented the relapse but in all probability 
have resulted in permanent cure. In any event the fair 
and full trial of it could not have eventuated more 
disastrously than its omission. Similar accumulation 
(gummy deposits) occurring in the spinal cord or at 
any point throughout the nervous system, producing 
paralysis in various localities and degrees, even in some 
instances perfectly simulating locomotor ataxia,§ and 
general paralysis of the insane, would be treated with 
equal benefit, through the same means and measures 
made use of in the early stages of the foregoing case. 
Inunctions of the mild mercurial ointment, a drachm 
morning and evening, instead of, or even in cases of 
urgency, in addition to, the administration of mercurials 

* London Medical Ti?nes and Gazette, Feb. 7, 1877. 

fCornil and Ranvier, Pathological Histology. Am. Ed., p. 331. 

\ Physiological Pathology of Syphilis. Otis. Putnam's Sons, 1881. 

§ See Professor Erb's paper " On the Role of Syphilis as a Cause of 
Locomotor Ataxy," in "Transactions of the International Medical Con- 
gress," seventh session. London, 1881. Vol. ii., p. 32. 



SYPHILIS AND THE GENITOURINARY DISEASES. 203 

internally. The iodide of potassium might also in 
obstinate cases be carried up to its highest point of toler- 
ance, or until the urgent symptoms yielded. As high as 
2 ounces of the iodide in the 24 hours have been admin- 
istered, with final relief of grave destructive late lesions 
of syphilis." 

The varieties of syphilitic sequelae, dependent upon 
locality and tissues involved, it will readily be seen, 
may be interminable. If such lesions are, as is claimed, 
dependent upon obstructed lymphatic channels or 
spaces, it will readily be seen that they may occur at 
any point in the human organism to which nutritive 
material is carried. The attempt to classify them in 
regions, organs, and tissues, while aiding in the study 
of special symptoms and local disturbances due to their 
initiation, development and progress, unless suitably 
guarded by explanation, is open to the objection that 
from this fact they are liable to be made the subjects of 
consideration as so many varieties of disease rather than 
the same variety simply modified in appearance and 
effects through the influence of locality. It will be re- 
called as a significant fact that no matter what the 
locality, appearance, or symptoms of presumably syph- 
ilitic origin, one and the same line of treatment is indi- 
cated in every lesion occurring throughout that period 
of syphilis known as the tertiary and quarternary stages 
of syphilis, or the period of syphilitic sequelae. 

* Genito-Urinary Diseases with Syphilis. Van Buren and Keyes. 
Appleton & Co., New York, 1874, p. 570. 



204 PRACTICAL CLINICAL LESSONS ON 



LESSON XXITI. 



SYPHILIS OF INFANTS AND HEREDITARY SYPHILIS. 

Does not differ essentially from syphilis of adults. There must always 
be a syphilitic disease-germ to initiate the disease. Difference in 
syphilis of the embryo. Syphilis of the infant and syphilis of the 
adult all dependent upon the same influences, modified by the nature 
of the tissues involved. Treatment of all must be based on same prin- 
ciples. Reasons for this view. Syphilis as a result of obscure hered- 
itary influence not accepted. Reasons in support of this view. Dis- 
ease of embryo or infant often resulting from pre-existing syphilitic 
disease of parents. Not necessarily syphilitic. No authenticated 
cases of syphilis in embryo, or infant conceived after contagious or 
active stage of syphilis in parents has passed. 

If the position taken in the preceding lessons is cor- 
rect — viz., that syphilis is the result of undue prolifera- 
tion of germinal cells, brought about by the influence of 
a syphilitic cell or disease-germ, which has been brought 
in immediate contact with a healthy germinal cell, then 
all syphilis must be attributed to a similar cause. There 
must always be a syphilitic disease-germ to initiate the 
disease. The different modes through which contact, in- 
itiating the disease in adults or children, is effected, has 
already been explained. Syphilis in infants cannot dif- 
fer from this, except so far as the disease is modified by 
the immature tissues in which the disease is developed. 
The treatment of syphilis of infants must be based on 
the same principles as that for adults. In this view, 
strictly speaking, there can be no such thing as heredit- 
ary syphilis. If, as has been shown by citation of numer- 
ous instances, notably by results of the recent exten- 
sive observation of M. Fournier and others — the infec- 
tious property of syphilis is self-limited, and does not 
continue beyond a period of three or four years, all 
cases of transmitted syphilis beyond such period, 
whether by immediate contact or through alleged 
hereditary influence, becomes impossible. If it can be 
shown that no well-authenticated case of transmission 



SYPHILIS AND THE GENITOURINARY DISEASES. 205 

of syphilis has occurred beyond a period of three or four 
years, as has been claimed, then an hereditary influence 
extending through generations cannot be accepted. 
The necessities for the production of syphilis require for 
its initiation a disease-germ of syphilis. The development 
of the disease, following its contact with healthy cell 
elements, is well understood — a certain definite course 
in its progress is recognized as necessary in all cases — 
a stage of proliferation with contagious non-destructive 
lesions — the so-called primary and secondary periods — 
then a stage of accumulations of lymphatic elements, 
non-contagious, but which produce destructive lesions 
through mechanical interference with processes of nutri- 
tion. In order, therefore, to the production of the dis- 
ease in the adult, in the infant, or in the embryo, the in- 
fecting cell of syphilis must first be brought in contact 
with healthy cell material. No mysterious hereditary 
influence is necessary, or can be admitted. If the dis- 
ease-germ of syphilis by direct contact with external 
parts or through its amoeboid power traversing tissue, 
reaches healthy cell material, whether in the adult, the 
infant, or the embryo, then the syphilitic influence is 
directly transmitted, and its development must be gov- 
erned by the same laws that characterize its progress in 
the known behavior of the disease in the adult, modified 
to greater or less extent by the age and degree of sta- 
bility of the tissues in which the disease is developed. 
First, the localized proliferation and accumulation of 
cell material not necessarily destructive ; second, accu- 
mulations of cell material, which induces destructive 
action through interference with processes of nutrition. 
In this way it will be seen that syphilis in the embryo, 
syphilis in the infant, syphilis in the adult, is the legiti- 
mate result of similar — in point of fact identical, proc- 
esses — producing results which, while apparently differ- 
ing in many respects, may yet be explained in complete 
harmony with the known behavior of syphilitic disease 
in the adult. It is undoubtedly the fact that much dis- 
ease in foetal and infantile life results from pre-existing 
disease in the generative organs of the parents, who 
Vave been subjects of syphilis — but that any syphilitic 



206 PRACTICAL CLINICAL LESSONS ON 

disease, proven to be such by its power to transmit 
syphilis, has been communicated to healthy persons, by 
infants conceived after the active or contagious stage of 
syphilis has passed, there is no well-authenticated evi- 
dence to prove. 



SYPHILIS AND THE GENITOURINARY DISEASES. 225 



LESSON XXVI. 

DOES DIAGNOSIS OF CHANCROID REST UPON CHARACTER 
OF LESION OR ON ITS SOURCE. — ANALYSIS OF CASE 
IN POINT. 

Inoculability not a sure test as to origin of lesion. Clinical case in illus- 
tration of the fact that the elements of destructiveness and contagious- 
ness do not depend upon a specific virus. Mode of development of 
chancroid. Varieties of chancroid. Modifications from syphilitic in- 
fluence. 

In the previous lesson, the diagnosis of simple origin, 
of the apparent chancroid, was made, in the last case 
presented. 

It is, however, very evident that if no lesion is to be 
accepted as a chancroid, unless proved to have arisen 
from contact with a lineal * chancroid, the specific nature 
of chancroid may be accepted as demonstrated. The 
diagnosis, then, in any instance, will not rest upon the 
character of the lesion, but upon its source. Thus in 
the case cited, according to this ruling we have not a 
chancroid. A suppurating sore occurs in a lady who 
never before had an ulcerative lesion of any sort ; it 
makes its appearance on the urethral orifice a few days 
after contact with her husband, who has a sore on his 
urethral orifice, which appeared a few days after a con- 
tact with another woman, and was followed by a sup- 
purating bubo. It looks like a typical chancroid ; it 
behaves like it, in its destructive tendency, in its advance 
and its retrograde under treatment, and its final cicatri- 
zation after about two months' duration, under improved 
hygienic conditions, and yet it is not accepted as chan- 
croid, and why ? First, because it is clearly not the 
product of a lineal chancroid. This is, of course, suffi- 
cient for those who thoroughly accept the specific nature 
of the disease ; but there are others, who decide this 
lineal matter by the inoculability or non-inoculability of 

* i.e. Descended in unbroken line from the first chancroid as claimed 
by those who assert its specific origin. 



226 PRACTICAL CLINICAL LESSONS ON 

its secretion. With them the production of true chan- 
croid, by inoculation of a given secretion, proves that 
secretion to have come from a chancroid. Assertions 
to this effect, would appear to be the result of experi- 
ence among the class most prone to suffer from the 
results of venereal dissipation, where probabilities are 
all in favor of chancroid having been acquired from 
contact with chancroid, and among whom the contagious 
element of the chancroid is kept by various influences 
up to a high point of activity. 

There can be, however, no question that chancroid, 
proven of direct lineal descent from a typical chancroid, 
may be met, which is inoculated with difficulty and 
which is but feebly destructive ; that in point of fact, 
chancroid descended from typical chancroid is seen of 
every grade of destructive and contagious power. Ex- 
periments have proved that the true chancroidal virus 
gradually loses its power by repeated inoculation, and 
also that various conditions of health may prevent the 
success of inoculations with fresh virus and under cir- 
cumstances otherwise favorable. "Susceptibility to 
inoculation is impaired, or even lost, temporarily, dur- 
ing the occurrence of any febrile attack or great de- 
pression of the vital powers." * 

Susceptibility is also increased by constitutional dys- 
crasia, of various kinds : thus the syphilitic dyscrasia, it 
is well known, predisposes to purulence. Typical chan- 
croids, destructive and inoculable in generations, have 
been repeatedly proven to result from the inoculation of 
pus from an irritated syphilitic chancre, also from the 
purulent secretion of secondary syphilitic lesions, and 
also from scabies and acne. Baumler, a recent German 
authority, says: "According to its source and mode of 
its origin, as well as the susceptibility of the individual 
affected, will the pus poison and evince this (chancroidal) 
property, in greater or less degree. Whence the pus de- 
rives this property, in what it consists, and why all pus does 
not possess it alike, are questions yet to be solved." \ 

Inoculability, then, is not a reliable test as to the origin 
of a sore. 

* Bumstead, p. 317. 

f Zeimssen, Vol. III., Am. Ed., pages 94 and 95. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 227 

Again, inoculation of a leucorrhceal secretion, especi- 
ally from a cervicitis, or a metritis, has been claimed 
capable in certain instances of producing inoculable 
sores. This is further proven by the following extract 
from a distinguished authority: 

* " In March, 1840, a woman from the neighborhood 
of Aries, aged 22, and remarkably beautiful in form and. 
appearance, was thoroughly examined, as was supposed,. 
by Prof. Lallemand, and no symptom of venereal disease 
was discovered. This examination was made at the re- 
quest of an officer, who complained that she had infected 
him. Several similar complaints being subsequently 
made by others, she was sent to the police station, where 
she was again examined by M. Delmar, in the presence 
of a considerable number of students. The neck of the 
uterus still appeared healthy, but on pressing it with the 
speculum it discharged a muco-purulent fluid, which 
was inoculated, in four places, upon the patient's thigh, 
with the effect of producing four well-marked chancroids" 

In this connection it will be interesting to recall the 
cases in the previous lesson, where ulcerated lesions on 
the penis resulted upon contact with virtuous women, 
who suffered only with sub-acute metritis. 

How do these women differ from the beautiful woman 
of Aries, as to the character of these uterine secretions? 
Contact with them produces sores proven to have a 
contagious property. Must we then say that they are 
subjects of chancroid in the interior of the cervix, or 
uterus? The woman of Aries communicated chancroid, 
because she had a uterine leucorrhcea, and because she 
was a prostitute, not because she had a chancroid. The 
most rigorous and repeated examinations failed to find 
any chancroid upon her, and yet she was the source of 
chancroid to others. 

The man, whose urethral sore communicated a similar 
sore to his wife's urethra, had not chancroid, because 
his sore was acquired from contact with menstrual fluid 
under circumstances of unusual excitement, from a lady 
of supposed virtue, and not from a prostitute. 

The foregoing cases and remarks are chiefly intended 

* Bumslead, p. 359. 3d Ed. 



228 PRACTICAL CLINICAL LESSONS ON 

as a preface to the final and important statement, viz., 
that the elements of destructiveness and contagiousness 
in a venereal lesion are not, in my opinion, dependent 
upon a specific virus, but are engendered by various 
causes and conditions, and that, clinically, we shall have 
to deal with venereal lesions in every degree of activity, 
which activity will be found to depend as frequently 
upon the constitution and circumstances of the patient, 
as upon the variety and origin of the sore from which 
the chancroid was derived. We may then say that 
Chancroid 

ist. Begins as a destructive process, either upon a 
pre-existing lesion, or upon sound tissue. It is usually 
set up by contact with the purulent secretion of a simi- 
lar destructive process, which had a similar origin, or 
which may have been developed from a suppurative process 
of a lower grade. 

2d. The destructive process thus initiated (either 
upon sound tissue or upon a pre-existing lesion) pro- 
ceeds steadily to the formation of a pustule, or an ulcer- 
ated surface, by a more or less rapid molecular necrosis. 
This necrosis, occurring under differing conditions, and 
in different localities, gives rise to characteristic forms 
of the chancroidal lesion, which may be described as 
follows, viz. : 

ist. The Chancroidal Abrasion ; 2d. The PUSTULAR 
Chancroid. 

These may be again divided into the slowly destructive 
and the actively destructive varieties. We may have as 
modifications of these, 

From Condition. From Locality. 

The Indurated Chancroid. The Follicular Chancroid. 

The Inflammatory " The Papulo Pustular " 

The Gangrenous " The Ecthymatous " 

The Phagedenic " The Sub-Preputial " 

The Serpigenous " The Chancroidal Bubo. 

The Bubonic Chancroid. 

The Urethral 

The Rectal 
The Ex-Ulcerous Chancroid of Clerc, and the Ulcus Elevatum. 

Modifications of all the foregoing forms and varieties 
by the coincident development of implanted syphilitic ele- 
ments on the site of the chancroidal lesion. 



SYPHILIS AND THE GENITOURINARY DISEASES. 229 



LESSON XXVII. 

ORIGIN OF THE CHANCROIDAL ABRASION. 

Most frequent localities of chancroidal abrasion. Physical appearances. 
Pustular chancroid. Mode of origin. Clinical case in illustration. 
Chancroid divided into two varieties according to activity of destruc- 
tive process. Cases in illustration. Character of chancroid dependent 
upon its source. Chancroid modified by various influences and causes. 

Abrasions of mucous membrane are frequent as the 
result of violence during- the act of coition : they occur 
most frequently about the fourchette and the vestibule 
of the female, and about the preputial orifice, and the 
frenum, and along the preputial reflection of mucous 
membrane in and behind the fossa glandis in the male. 

All injuries of this character, on being brought into 
contact with the secretion of an active chancroid, are 
at once inoculated, and the suppurative action is thus 
initiated over the entire surface of the lesion. It is to 
the abrasion, thus complicated, that the term chancroidal 
is applied. To the naked eye it appears at first like a 
simple scratch or chafe, but an examination of its secre- 
tion shows abundant pus corpuscles, within three or 
four days, and often within twenty-four hours. By the 
aid of a good magnifying glass the advancing molecular 
necrosis may be seen, in the dentated edges, in the 
minute sloughing points on the surface of the lesion, 
and the secretion is inoculable. Sooner or later, in ac- 
cordance with conditions which are known to render 
chancroidal lesions more or less active, the abrasion 
may be merged into the characteristic chancroid. Its 
shape, which at first corresponds with that of the sur- 
face inoculated, now changes, through the advancing 
ulceration. The edges become ragged and abrupt, the 
floor, excavated and covered with the debris of dis- 
organized tissue, gives rise to a profuse secretion of 
pus. The time for these changes in different cases may 
vary from a few days to several weeks. 



23O PRACTICAL CLINICAL LESSONS ON 



ORIGIN OF THE PUSTULAR CHANCROID. 

The pustular chancroid arises either from the erosive 
property of the chancroidal secretions which have been 
deposited in the folds of integument or mucous mem- 
brane, or from the absorption of the secretion into the 
follicles of mucous membrane, which have been bathed 
in the secretion of chancroid. 

The time of its appearance after contact varies from 
three or four days to eight or ten, and in certain 
authentic instances even longer. 

The follicular starting point of the disease, assumed by 
Cullerier, Bumstead, Acton and others, has been substan- 
tiated by a case which came recently under my obser- 
vation. Mr. W came to me complaining of having 

bruised his glans penis during a connection four days 
previous. On the morning following the indulgence the 
part felt very sore and was swollen and inflamed. These 
conditions had been gradually increasing in intensity, 
until he presented his case to me. I found the inferior 
portion of the glans much tumefied, from the meatus 
back to the fossa glandis, and for half an inch on either 
side of the median line (the frenum had been smoothly 
carried away by a chancroid ulceration, for which I 
had treated him a year previous). The injured part 
was swollen, and presented a smooth, shining surface 
of a deep red color. By the most careful examination, 
with the aid of a magnifying glass, I could not discover 
any point of abrasion or solution of continuity what- 
ever. I advised a simple water dressing, slinging up 
the penis, so that engorgement from the dependent 
position of the organ might be relieved, and as per- 
fect rest as possible obtained. He called on the follow- 
ing day, somewhat relieved, but in appearance the parts 
had not improved ; the color was even deeper than 
on previous examination. A wash of lead and opium 
was substituted for the water dressing, and the patient 
advised to keep the recumbent position. On the next 
day, the third from his visit to me, and the seventh 
from the impure connection, he again presented him- 



SYPHILIS AND THE GENITO-URINARY DISEASES. 23 1 

self. The tumefaction was much the same ; the color 
had deepened and was now of a violet tinge, and I dis- 
covered, as though under a glass, numerous pale 
whitish points varying in size from a pin's point to a 
pin's head, occupying a space a quarter of an inch 
broad and one third in length on either side of the 
median line on the inferior aspect of the glans. Previ- 
ous treatment was continued, and I saw my patient 
daily for three days following, making in all ten days 
from the connection. On the morning of the tenth day 
I discovered some half a dozen whitish points just under- 
neath the mucous membrane ; these were then opened 
into with a fine-pointed bistoury, and discharged minute 
quantities of pus. Under the magnifying glass, the lit- 
tle cavities left after the discharge of the pus were char- 
acteristic of chancroidal ulceration. In brief, all the 
points, some twenty or thirty in number, finally worked 
their way to the surface, occupying some three days 
longer, and they soon coalesced from the extension of 
the ulcerative process, resulting in a true chancroid, 
three fourths of an inch in length, by one third of an 
inch in breadth, occupying the site of the original white 
points. The first pustules were visible through the 
mucous membrane, but evidently deeper than its thick- 
ness, on the seventh day after the absorption. The first 
of these came to the surface on the tenth day, but it was 
not until the thirteenth that all had reached the mucous 
membrane on their outward march. Applications of 
the strong nitric acid resulted in a complete recovery 
in a few days. Occasionally single, chancroid is accom- 
panied as a rule, or soon followed, by others, in the im- 
mediate vicinity or at different points. Commencing 
usually as a fine whitish speck, scarcely larger than a 
pin's point, it soon increases in size, and, unless occur- 
ring on an already inflamed surface, presents a dis- 
tinctly inflamed border. Its progress (more or less 
rapid, according to circumstances and conditions which 
are known to increase or retard its activity) is by an 
acute ulceration, before which the tissues give way in 
irregular form, both at the edge and floor (as hereto- 
fore described in case of its advance from a previously 



232 PRACTICAL CLINICAL LESSONS ON 

abraded surface), accompanied with more or less local 
inflammation and pain. Its progress, like that of the 
chancroidal abrasion, is variable. In typical cases, 
under circumstances of usual health and condition, 
reaching to the size of a five-cent piece, and penetrat- 
ing to the depth of one or two lines, in the course of 
three or four weeks, while, under other circumstances, 
its depth and its extent may be greatly increased. 

These peculiarities of the action of the chancroid are 
the same, whether beginning on an abraded surface or 
as a pustule, and warrant the division of chancroid into 
two forms previously noted, viz., the slowly destructive 
and the actively destructive. 

To show you that this division is not simply a tech- 
nical one, I will recall four cases presented to you at 
our last two sessions, which illustrate the validity of the 
distinction. 

Case I. — Wm. B., waiter, about 25 years of age, gave 
a history of exposure through vicious sexual contact, 
eight weeks previously. Four or five days after, he 
noticed several white pimples on his prepuce behind 
the fossa glandis. He touched them with "blue stone" 
from time to time, and after a week, others came on 
his glans penis. He then used a wash and kept them 
clean, but they refused to heal until he went to Charity 
Hospital, about a week ago, seven weeks, after their 
appearance. Here the sores on the prepuce were 
cauterized, on several occasions, with nitric acid, also 
three about the size of a pea on the glans. His general 
condition as he came before us was fair, not rugged. 
He presented several superficial cicatrices on the in- 
ternal reflection of the prepuce, and a raw surface 
about the size of a three-cent piece, yet unhealed, but 
granulating well. On the glans, were three fresh cica- 
trices, which, as I was careful to show you, matched 
exactly upon three distinct cicatrices on the prepuce 
when drawn forward. This case I presented as chan- 
croid of the first variety ; demonstrated as slowly de- 
structive and also contagious, as proven by auto-inocu- 
lation. 

Case II. — A blacksmith, aged 45, was shown you in 



SYPHILIS AND THE GEXITO-URIXARY DISEASES. 233 

contrast. A large pallid man, evidently in low condi- 
tion. Just two months before, he also had a connec- 
tion, and no trouble resulted for the next ten days, 
when his attention was attracted to his penis by sore- 
ness. He then discovered three inflamed pimples, one 
on a redundant prepuce and two on the body of the 
penis. These progressed steadily, and thinking they 
were simple boils, he neglected them until the scabs 
came off a few days ago, when he found deep ulcera- 
tions in their place, each as large as a dime. He was 
admitted to Charity Hospital, and the sores, w T hich 
were recognized as typical chancroids, were cauterized 
with nitric acid. When shown to you, three days after, 
they were still of same size before mentioned, and fully 
one fourth of an inch deep, penetrating fully and sharp- 
ly the swollen integument. This case was presented as 
illustrating the actively destructive variety of chancroid. 
With much the same history as the first, it was yet 
seen to be in marked contrast with it in regard to the 
activity of the destructive process. There was no his- 
torv of any antecedent syphilis in either case. 

Case III. was of a lad of twenty. He was in good 
health, history of an impure connection four weeks pre- 
viously. A pimple near the frenum appeared five or six 
days after ; this he treated with repeated applications 
of " blue-stone," and it healed in a couple of weeks, hav- 
ing carried away the frenum. A soreness of the right 
groin then set in, and culminated in an abscess ; this I 
opened before you, discharging about an ounce of un- 
healthy looking pus. 

Both its appearance and course w r ere spoken of as 
characteristic of the chancroidal bubo. The locality 
of the original sore was pointed out, as one most liable 
to be followed by such an accident, inasmuch as the 
lymphatic vessels, connecting this point with the glands 
of the groin, are known to be numerous and superficial. 
No other cause for such a complication could be elic- 
ited. 

Case IV. presented to you last week came to our 
clinic the week previous, too late in the hour to be 
available as an example. The young man, 25 years of 



234 PRACTICAL CLINICAL LESSONS ON 

age, gave a history of impure connection the week 
previous, and had just discovered a little sore just 
within the urethral orifice. A little feeling of hardness 
associated with this sore and the long interval since the 
connection, gave rise to suspicion of syphilis. In order 
to clear this up, two inoculations were made under the 
left nipple of the patient by Dr. Bangs, our chief clini- 
cal assistant, and the patient was ordered to report on 
the following Saturday, two days after ; this he failed 
to do. He was presented to you one week after, with 
a sore that had penetrated fully one third of an inch, 
and had completely carried away the right side of the 
meatus, exposing the urethra for that distance. The at- 
tempted inoculations, as shown you, were wholly abor- 
tive, although as I saw them one half hour after the 
puncture, they were surrounded by a congested areola 
half an inch in diameter. 

This case I presented as demonstrating several points: 
ist. The long interval of apparent incubation. 2d. The 
slow progress of the lesion up to the week previous, 
thus marking it as belonging to the slowly destructive 
variety of chancroid, if it were chancroid. 3d. The 
sudden change from the slow to the actively destruc- 
tive variety. 4th. The failure of a carefully performed 
inoculation of the secretion of the lesion upon the per- 
son of the patient, thus going to prove that a destruc- 
tive chancroid may under certain conditions fail to give 
an affirmative proof b}Mnoculation, as claimed by Bock 
and others. 

Now while I do not present these cases as absolutely 
proving the points I desire to illustrate, as there may 
be various valid objections urged against them, yet I 
claim that they form links in a chain of evidence show- 
ing that chancroid is of variable quality and force, and 
also that the quality and force is determined not by any 
specific virus but by circumstances and conditions. It 
will be well for all who study and treat this disease, to 
be cognizant of this, and to consider the causes which 
are known to effect the degree of destructiveness and 
contagiousness in each case, instead of attaching too 
great importance to the dogmatic and unsupported 



SYPHILIS AND THE GENITO-URINARY DISEASES. 235 

assertions, of those who claim one continuous lineal 
descent; for all inoculable and destructive venereal 
sores. 

It may, I think, be safely claimed that the character 
of a chancroid is greatly dependent upon the degree of 
activity of its immediate predecessor, and that it may 
itself be modified or intensified by the following influ- 
ences : 

1st. General condition of the person so inoculated, 
especially in relation to any diathesis or dyscrasia. 

2d. Locality of the inoculation. 

3d. Influence of alcoholic stimuli, low and irregular 
living, etc. 

4th. Local sources of irritation, such as standing at 
work, walking, or horseback exercise, indulgence in 
•coitus, uncleanliness, etc. 

5th. Application of external irritants, administration 
of internal medicines, especially mercurials. 

For the convenience of description, various names 
have been applied by authors to designate the several 
modifications of chancroid. These have been already 
cited, and will be seen to fall naturally under two heads, 
as modified by condition and locality. 



236 PRACTICAL CLINICAL LESSONS ON 



LESSON XXVIII. 

MODIFIED BY CONDITION. 

Chancroid modified by condition. Characteristics of simple chancroid. 
Induration produced by irritation. Differentiated from syphilitic in- 
duration by results of treatment. Inflammatory chancroid. Descrip- 
tion of. Causes of. Gangrenous chancroid. Causes of. Character- 
istics of. Phagedenic chancroid. Definition of. Characteristics of. 
Cases in which it usually occurs. Serpigenous chancroid. Description 
of. Causes of. 



FIRST: THE INDURATED CHANCROID. 

. The uncomplicated chancroid has a soft base and 
edge differing in suppleness but little, if at all from 
the surrounding tissue. In this condition we have a 
valuable diagnostic mark separating chancroid from the 
initial lesion of syphilis, which, in typical cases, presents 
a distinct induration of the tissue on which the lesion is 
located. Venereal sores often present, however, about 
which a varying amount of induration is present ; not 
seldom occurring at an early period in a chancroidal 
lesion, before the loss of substance is well marked, or 
coming on later, in a well-marked chancroid, giving rise 
to suspicion of underlying syphilitic action. It is well 
then to understand, that such induration may result from 
any form of irritation, and may be a purely inflammatory 
aggregation of cell material. Chancroids thus compli- 
cated are termed indurated. The test of the nature of 
the induration, in any case, is by simple treatment. If the 
induration is thus rendered .more dense and sharply de- 
fined, it will prove, as a rule to which there are few 
exceptions, that it is the result of true cell growth caused 
by the syphilitic influence, and that the lesion is either 
the initial of syphilis complicated by accidental ulcer- 
ation, or that it is a true chancroid complicated with 
syphilis. 

If, on the contrary, the induration disappears wholly 
under the influence of rest and local sedatives, and the 



SYPHILIS AND THE GENITO-URINARY DISEASES. 237 

sore heals without subsequent induration, it is of an in- 
flammatory character, and the lesion so complicated is 
proven of purely local nature, and has thus been but an 
indurated chancroid. 

SECOND : THE INFLAMMATORY CHANCROID. 

Instead of becoming indurated under various causes 
of irritation as in the previous variety, the tissue sur- 
rounding and underlying the chancroid may become 
more tender and swollen, assuming a puffy appearance, 
and the surface more intensely red and extended. 

This condition may supervene upon any stage of 
chancroid, whether slowly progressing or healing, and is 
the evidence that a more rapid destructive action has 
been initiated, or is imminent. 

The same condition may obtain, on the early appear- 
ance of the chancroid, as a result of intensity in the 
secretion inoculated, or from constitutional taint, excess, 
sexual and alcoholic, as well as from local irritation. 

THIRD : THE GANGRENOUS CHANCROID. 

This is but the fruit of the unrelieved inflammatory 
form, usually the result of interference with the circula- 
tion of the part by swelling and inflammatory infiltration 
of the tissues, in which case, sloughing of contiguous 
structures occur en masse ; especially is this apt to take 
place in debilitated and dissipated subjects. When 
occurring upon persons in good condition, it is the re- 
sult of some mechanical constriction, as in case of sub- 
preputial chancroids complicated with phimosis. 

The occurrence of gangrene, in such case, once an- 
nounced by the foetid odor, if not arrested by treatment, 
will require but a few hours for the deep red surface of 
the inflamed prepuce to turn black, and the slough to 
disintegrate and separate from the living tissue, at or 
near the line of constriction. The effect of the gangre- 
nous accident, is to destroy all contagiousness in the 
associated chancroid, and the parts heal, after the falling 
of the slough, as if no such complication had been pres- 
ent. 



238 PRACTICAL CLINICAL LESSONS ON 

FOURTH: PHAGEDENIC CHANCROID. 

This term is usually applied to all chancroids which 
progress with unusual rapidity. Hence it is made to 
include all degrees, from the inflamed chancroid, to that 
form in which a sloughing of tissues takes place en masse. 
Instead of a simple death of tissues through arrest of 
circulation, it is the result of an added destructive ele- 
ment, in some respects similar to that which causes 
hospital gangrene. It is characterized, in the milder 
forms, by gradual advance in destruction of tissues, in 
spite of the ordinary treatment, and of circumstances 
favorable to recovery ; still further by the occurrence 
of a putrefactive change. This is heralded by a mawk- 
ish and, finally, by a distinctly gangrenous odor and an 
increasing rapidity of the destructive action in all the 
dimensions of the lesion, involving any and all tissues 
and vessels. Progressing in aggravated cases with 
great rapidity ; destroying important parts even within 
a few hours. Accompanied, whenever the loss of tissue 
is at all considerable, by pain often very great, and by 
more or less general constitutional disturbance. This 
grave complication, is confined almost wholly to sub- 
jects of intemperate habits, who have also been subjected 
to low conditions in living, although it may take place 
in persons who, while living under favorable hygienic 
conditions, are of scrofulous habit; or it may be the 
result of contamination from the secretion or exhalations 
from similar processes. 

FIFTH: THE SERPIGENOUS CHANCROID. 

This a variety of the phagedenic, which is quite inde- 
pendent of any tendency to sloughing or gangrenous 
action, and is confined solely to the integument. It is 
recognized, in its early stage, by obstinate resistance to 
treatment. Progressing very slowly, and superficially, 
healing on one side under treatment, while progressing 
on the other ; healthy-looking granulations springing up 
here and there — even little islands of healthy-looking 
tissue appearing, apparently as the result of some effi- 



SYPHILIS AND THE GENITOURINARY DISEASES. 239 

cient application, and then melting away under its con- 
tinuance. Finally, in certain cases, creeping over large 
tracts of integument, the groins, perineum and buttocks, 
and in forms which have suggested the name of this 
complication. The secretions of this variety of sore are 
thin and copious, but not inclined to form incrustations. 
They have the power of producing a chancroidal sore 
by auto-inoculation. It does not necessarily produce 
the serpigenous variety when inoculated upon other 
persons. The subjects of this accident are usually of 
a scrofulous diathesis. 

The modifications of chancroid, from locality, are 
chiefly important in regard to treatment. 



240 PRACTICAL CLINICAL LESSONS ON 

LESSON XXIX. 

DIAGNOSIS AND TREATMENT OF CHANCROID. 

Difficulties in diagnosis. May be confounded with herpetic lesions. 
Treatment of. Modified by condition. Reasons why insignificant 
lesions often require great consideration. Management in early stage. 
Treatment by excision, by cauterization. Best methods described. 
Character of subsequent treatment. Various applications. Diagnosis 
and treatment of the indurated chancroid, of the serpigenous chancroid, 
of the follicular chancroid, of the papulo pustular variety, of the ecthy- 
matous form. Diagnosis and treatment of sub-preputial chancroids. 
Possible source of error in diagnosis. 

When seen in the earliest stage — viz., the Chancroidal 
Abrasion — it is difficult, and often impossible, to decide 
whether it is the result of irritation through some vi- 
cious vaginal secretion or lesion other than chancroid, or 
not. Hence all lesions, first seen as abrasions, should 
be treated tentatively, until the characteristic chan- 
croidal ulceration surface is developed. A mild, astrin- 
gent sedative lotion, say three grains of the acetate of 
lead to the ounce of rose water, may be applied on a thin 
film of borated cotton three or four times a day. If the 
lesion is a pustule, and has made its appearance a day or 
two, or three or four after exposure, it may be of her- 
petic origin. A single herpetic pustule is not very 
common. A solitary pustule, following five or six days 
after a suspicious connection, is more apt to be chan- 
croid. Careful examination will sometimes detect one 
or more little vesicles, or their remains, in the immediate 
vicinity of the pustule. This warrants the inference 
that the pustule had its origin in a vesicle, and was thus 
of herpetic nature and not chancroid, which always 
begins as a pustule. We may venture, in such case, to 
expect that simple treatment will suffice, especially if to 
this is added rest and freedom from irritation of every 
kind. Nothing is more essential, in the treatment of 
any inflammatory lesions, than rest and cleanliness. This 
is eminently true of chancroid, and all the lesions that 
may be mistaken for it. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 24I 

If the suspected lesion increases, in spite of rest, clean- 
liness and a mild sedative lotion, it is safe to include it 
at once under the class Chancroid. If it is inclined to 
be superficial and sluggish, we will designate it as of the 
slowly destructive variety, and treat it with a solution 
of sulphate of iron, applied on a film of cotton two or 
three times daily. This, or an application of a mild 
solution of carbolic acid, is often promptly curative. If 
there is much redness or tenderness, the watery extract 
of opium may be added, thus : 

3 Ferri Sulph. grs. X. 
Ext. Opii Aq. grs. X. 
Aq. ad. % i. 

M. 



^ Acid Carbolic, grs. V. 
Sol. Morph, U.S. P. l'\. 

M. 

The general condition should also be considered. If 
there is reason to suppose the patient especially inclined 
to suppurative trouble from scrofulous diathesis, or 
from general debility, or personal idiosyncrasy, in addi- 
tion to any measures addressed to the general health, it 
may be well to administer small doses of the sulphide 
of calcium, -fa gr. every two hours, either in freshly 
made solution or in parvules. These measures, even in 
the very slight forms of suppurative lesion (which are 
oftentimes difficult to distinguish whether of true chan- 
croidal origin or not), will in some cases be found worth 
considering and adopting. Many cases of most insignif- 
icant character, in a surgical point of view, cause great 
anxiety and mental suffering, and should be met, at the 
outset, with the greatest consideration from the surgeon, 
not only because of conditions present, but because of 
the possibilities that these innocent-looking lesions may 
hide the progress of a syphilitic inoculation. If under 
the above mentioned mild applications, the sore (or sores, 
as there are commonly several) heals rapidly or slowly, 
and, finally, cicatrizes completely, it is yet most important 
to keep in mind the fact, that sometimes, just such lesions, 
even weeks after an apparent cure, begin slowly to in- 



242 PRACTICAL CLINICAL LESSONS ON 

durate and finally demonstrate that a syphilitic infection 
has been initiated. It is by no means infrequent that 
such an accident occurs under cover of a supposed 
chancroid or an herpetic eruption ; or an abrasion irri- 
tated into seeming viciousness, by simple vaginal secre- 
tions, or a want of cleanliness or care. 

If, however, the lesion shows early, that it belongs to 
the actively progressive variety of chancroid ; if it be- 
comes sensitive, and progresses in depth and extent, 
with undermined and irregular edge, and worm-eaten r 
sloughy floor (and this may often be seen under a good 
magnifying glass a short time after its appearance), ac- 
tive measures are often promptly curative. If the ulcer 
is situated on the free margin of the prepuce, it may 
sometimes be removed by excision — previously cleans- 
ing the parts with a io-grain solution of carbolic acid — 
and cutting through the entire thickness of the prepuce, 
then stitching the edges together. Union by first in- 
tention may thus be secured. Great care will be neces- 
sary to prevent inoculation of the cut surfaces, in which 
case, the chancroid will be greatly increased. When situ- 
ated on the reflection of the prepuce, or in the fossa 
glandis, or on the glans penis, or in the vicinity of the 
frenum, or in any locality on the male or female genitals, 
where they may be thoroughly and easily exposed, and 
when the inflammatory action is not great, the complete 
destruction of the chancroid — one or more — should be 
effected at once. The best and most convenient means 
is by application of the strong nitric acid. The solid 
nitrate of silver stick is often used for this purpose. 
This is not sufficiently powerful to be depended upon. 
The actual cautery is excellent, but formidable, requiring 
ether, to be well borne. The nitric acid may always be 
at hand, and is, when well applied, thoroughly efficient 
in the great majority of cases. A convenient method 
of application is by means of a film of cotton, wound 
upon the point of a sharpened match or a wooden tooth- 
pick, using only enough to hold a drop or two of the 
acid. It may thus be carried to the surface of the chan- 
croid without danger of dropping on healthy tissues. 
Apply freely and let it soak in, until the floor and edge 



SYPHILIS AND THE GENITO-URINARY DISEASES. 243 

are completely saturated, repeating- the application, if 
necessary, until this is effected. A small chancroid re- 
quiring a minute or so, but one the size of a dime may 
require several. If favorably situated, the size of the 
lesion does not contraindicate the attempt to destroy it 
in this manner. When the saturation with the acid is 
complete, a bit of cotton, soaked in a solution of acetate 
of lead and extract of opium — 10 grains each to the 
ounce of water — may be applied. If the sores are mul- 
tiple, or large, placing the patient under the first effect 
of ether, for the application, is very desirable. The 
resulting slough, usually falls off within from three to 
five days, and, if the application has been effectual, a 
healthy granulating surface will be left. This heals 
readily under the slight stimulation of a weak solution 
of carbolic acid — 5 grains to the ounce. Should the 
ulcerative action show a disposition to return, a second 
application may be made. This may even be required 
a third or a fourth time, if great care has not been taken 
to destroy all the tissue involved in the chancroidal 
process. If, instead of active destructive action, there 
should simply be a sluggish and unhealthy condition of 
the sore remaining, this will be best treated by applica- 
tions of iodoform in powder or in combination with 
equal part of vaseline : 

^ Iodoform, 3 i. Iodoform, 3 i. 

Vaseline, 3 i. Balsam Peru, 3 i. 

Oleum Rosae. X. M. 

M. 

If the secretion is very profuse, 10 grains of tannic acid 
may be added. The odor of iodoform is often an insu- 
perable objection to its use. The addition of balsam 
Peru, or a few drops of any of the essential oils — laven- 
der, bergamot, neroli — or ten grains of thymol to the 
dram of iodoform, will sometimes make it endurable. 
But the best deodorizer for iodoform that I have found 
is the oil or attar of roses, in the proportion of one drop 
of the oil to 3 i. of iodoform. Nothing favors the best re- 
sults of applications, and the most rapid healing, so effect- 
ually as complete rest of body and mind. 



244 PRACTICAL CLINICAL LESSONS ON 

DIAGNOSIS AND TREATMENT OF THE INDURATED CHAN- 

CROID. 

One of the chief diagnostic points in chancroidal 
sores, is the freedom from positive induration ; a supple- 
ness of the tissues on which they are situated. A certain 
degree of induration, however, may be present from 
irritant or even astringent application, or friction by the 
clothes of the patient, raising the question as to whether 
or not this is the result of syphilitic infection. In such 
cases the sore should first be treated by removal of all 
irritating surroundings, by rest, and an application of the 
lead and opium dressing. If the induration is not syphi- 
litic, it will pass off under this treatment, when the 
destructive method may be pursued as previously indi- 
cated. 

The neglect of cleanliness, undue exercise, long stand- 
ing position or irritant applications, irregular hours, or 
alcoholic excess, especially in persons of dissipated 
habits and low genernl condition, often causes a highly 
inflammatory condition of the chancroid. The imme- 
diate result of this, is to increase pain and swelling of 
the tissues in the vicinity of the chancroid, and to ac- 
celerate the destructive action. Soaking the parts with 
opiated water as hot as can be borne, and as continuously, 
with attention to the general care of the patient, is the 
most prompt way of reducing this complication. If the 
lesions are upon a female, prolonged hot sitz baths are 
essential. 

DIAGNOSIS AND TREATMENT OF THE PHAGEDENIC 
CHANCROID. 

If relief does not follow, the phagedenic condition 
may be superimposed upon the inflammatory. Still 
more rapid, destructive action with putrescent odor, 
the true " molecular gangrene " takes place as alluded 
to in the previous description of this, form of chancroid. 
When rapid destructive action is thus set up, and impor- 
tant parts are threatened, a prompt and thorough soakage 
of the shreddy, pultacious, sloughy surface with strong 
nitric acid, is indicated, or, better still, an application of 



SYPHILIS AND THE GENITO-URINARY DISEASES. 245 

the actual cautery, repeated from time to time, until, by 
application of hot water, or by the aid of charcoal 
poultices, the slough is removed. Free use of the iodo- 
form in powder is also efficacious, not only for its disin- 
fectant but for its anaesthetic effect. The pain in rapidly 
destructive lesions of this sort is often very great, and 
the internal administration of opium acts beneficently. 
Twenty-grain doses of the potassio-tartrate of iron, as 
recommended by Ricord, may usually be administered 
to advantage. At Charity Hospital, the treatment by 
immersion in hot water by means of the sitz bath, with 
the water kept up to 100 F., has proved one of the most 
effective adjuvants in the treatment of sloughing phage- 
dena in females, (in whom applications are usually most 
difficult,) keeping the patient in for even ten or fifteen 
hours consecutively, and practically the same method 
for males. 

DIAGNOSIS AND TREATMENT OF THE SERPIGENOUS 
CHANCROID. 

This is notably the most rebellious to remedies of all 
the forms of venereal lesion. The size to which it insidi- 
ously attains under the usual treatment for superficial 
slowly destructive chancroids, (iodoform, carbolic acid, 
etc.,) is apt to cause a hesitation in resorting to applica- 
tions of nitric acid, acid nitrate of mercury, or any of 
the destructive agents in ordinary use for the treatment 
of chancroids. The apparently healthy granulations 
which spring up in the sore, and which often go on to 
production of new integument at one side, even while it 
is slowly melting away at the other, flatters the surgeon 
into the belief that mild measures, with appropriate 
constitutional treatment, will finally effect a healing. 
The result is, that serpigenous chancroids are occasion- 
ally met which have existed for years, and have come 
gradually to occupy many inches of surface. 

Especially is this seen in females, where the groins, 
the perineum, the entire vulva, the vaginal walls, the 
rectum, and the integument around the anus, may be con- 
tinuously involved. Few venereal hospitals, or out-door 



246 PRACTICAL CLINICAL LESSONS ON 

departments, are without specimens of this sort. Passing- 
usually under the title of chronic chancroid, (to which a sus- 
picion of obscure syphilitic constitutional vice is usually 
attached) they finally, in most cases, cease to receive 
any especial surgical care, and are often relegated to 
the class of incurables. The actual cautery is the one 
and only effectual remedy in the treatment of serpig- 
enous chancroid, no matter what the size or locality. 
Placing the patient under the influence of an anaesthetic, 
thoroughly apply at a white heat the cautery iron, or 
the platinum point of the gas, or the galvanic cautery, 
over the entire surface, following down into every crypt 
and sulcus, with the same animus as if dealing with a 
well-marked case of lupus excedens. Follow up with hot 
water immersions, sedative lotions, iodoform, etc., until 
the slough has separated, and as long as the new sur- 
face appears in satisfactory condition. If a retrograde 
is threatened, re-apply the cautery, as often and as long- 
as is necessary. This will not usually be required oftener 
than once in one or two weeks. Several cases within 
my experience, that had been considered beyond the 
reach of surgical aid, were, in this way, finally brought to 
a complete cure. 

The modifications of chancroid from location are 
noteworthy : first, in regard to diagnosis ; second, in 
regard to treatment. 

DIAGNOSIS AND TREATMENT OF THE FOLLICULAR 
CHANCROID. 

This commencing apparently underneath the mucous 
membrane, may quite readily escape observation, es- 
pecially when it commences deep in the substance of 
the follicle. The inflammatory swelling and redness 
often precedes the appearance of the pustule several 
days. 

DIAGNOSIS AND TREATMENT OF THE PAPULO-PUSTULAR 
CHANCROID. 

This is most often seen on the integument of the labia 
majora, and the mons veneris, of females. They are usually 



SYPHILIS AND THE GENITO-URINARY DISEASES. 247 

sluggish in character and quite inclined to burrow. 
They originate in a follicle, and are occasionally quite 
nume-rous, a dozen or more appearing at about the 
same time, and usually in connection with previously 
existing chancroids of considerable size, within or about 
the vulva. No applications have any effect which are 
not preceded by removal of the small scab and discharge 
of the contents of the pustule. After this, the treatment 
may be by prompt destructive agents, or by iodoform. 
If they are not discovered and treated early and effect- 
ually, the probabilities are in favor of coalition of the 
pustules, extension of the chancroidal process, ancl a 
stubborn persistence of the trouble. 

DIAGNOSIS AND TREATMENT OF THE ECTHYMATOUS 
FORM OF CHANCROID. 

This is covered by a broad thin brownish scab, is usu- 
ally on the integument of the penis or on the thigh, and 
may be mistaken for a simple herpetic lesion. Removal 
of the scab shows the characteristic chancroidal appear- 
ance of the edge and floor of the sore. Very often it 
belongs to the slowly destructive variety of chancroid, 
penetrating the thickness of the integument, or nearly 
so, but without much tenderness or surrounding inflam- 
mation. 

Treatment by prompt destruction of the diseased 
tissue, if active. If sluggish, application of iodoform, 
pure, or in combination with tannin, or balsam Peru, or 
by carbolic acid and glycerine, equal parts, applied in 
the same way as directed for use of strong nitric acid. 
For the same purpose, a solution of permanganate of 
potass, 2 grs. to the ounce of water, or sulphate of cop- 
per, 2 to 5 grs., may be applied on a little borated cotton 
or lint. This if on the penis should be protected by a 
thin wrapping of oiled silk, retained by a narrow cotton 
bandage, the end of which may be conveniently split 
into four tails, brought around, and tied. 

DIAGNOSIS AND TREATMENT OF SUB-PREPUTIAL CHAN- 
CROIDS. 

These require especial instructions for management, 



248 PRACTICAL CLINICAL LESSONS ON 

only when, on account of the narrowness or swelling of 
the preputial orifice, they cannot be readily exposed. 
If the phimosis is congenital, the existence of sub-prepu- 
tial chancroids may be infered by more or less swelling 
and tenderness following a suspicious sexual connection. 
The two difficulties with which they may be confounded 
are, balanitis and initial lesion of syphilis. Mild astrin- 
gent sub-preputial injections, as, 5 gr. solution carbolic 
acid, 10 gr. solution of sulphate of iron, or the lead and 
opium solution, may be used. If the phimosis is inflam- 
matory, persistent soakage of water as hot as may be 
comfortably borne will also be required. If the reduc- 
tion of swelling finally permits exposure of the affected 
parts, they may be treated according to conditions pre- 
senting. If, on the contrary, the swelling and sensitive- 
ness increase, and blood is mixed with the secretion — 
and this in spite of rest and fomentation — no time should 
be lost in slitting up the prepuce on the dorsum, pre- 
viously syringing out the preputial cavity with a 10 
grain solution of carbolic acid. The division may be 
done with the bistoury, and the cut surfaces thoroughly 
dried and cauterized with pure carbolic or nitric acid. 
But the best way of dividing the preputial tissue in such 
case is by introducing a bit of pure platinum wire, per- 
forating the prepuce at the base of the glans superiorly, 
and attaching it to the galvanic cautery battery and draw- 
ing it slowly through the intervening tissues. A small 
wooden tube, wetted, may be slipped over the wire to pro- 
tect the glans. Should the lesion be situated on the inner 
surface of the prepuce, or should the slitting not expose 
the whole diseased surface, the circumcision may be 
completed with the wire, or with a bistoury if pre- 
ferred.* Should the lesion piovetobe chancroid, the 
danger of inoculatiou of cut surfaces is always great, 

* A case of threatened sloughing of the prepuce from chancroidal action 
in its interior, occurred in my service at Charity Hospital not long since. 
The swelling was enormous, and extensive destruction of tissue was im- 
minent. The whole prepuce was removed by means of the galvano- 
cautery wire, without haemorrhage. Several chancroids in the fossae 
glandis were cauterized at the same time. The case went on to a rapid 
and complete recovery under antiseptic and simple applications. 



SYPHILIS AND THE GENITO-URINARY DISEASES. 249 

no matter what are the precautions taken ; but the dan- 
ger of damage to the glans penis, through the chan- 
croidal action, if not arrested, by relieving tension and 
by potent local application, is so great that the inocula- 
tion of the entire cut surfaces is a lesser evil. The 
after-treatment of the circumcision, under such circum- 
stances, is the same as ordinarily pursued, until some 
evidence of chancroidal action is manifest. In this and 
in the chancroids or other lesions which may be left on 
the glans or elsewhere, the same application already 
described for the lesions on open surfaces, will be re- 
quired. It must not be forgotten that an initial lesion 
of syphilis, irritated by confined secretions, may simu- 
late a chancroid in the inoculability of its secretion, and 
that a chancroid may be irritated so that induration 
shall be present, simulating that of the initial lesion of 
syphilis. Previous instructions as to diagnosis in such 
doubtful cases will guide. 



250 PRACTICAL CLINICAL LESSONS ON 



LESSON XXX. 

DIAGNOSIS AND TREATMENT OF CHANCROIDAL BUBO 
AND BUBONIC CHANCROID. 

Manner in which these lesions occur. Definition. Usual teachings in 
regard to the chancroidal or virulent bubo. All buboes, not syphilitic, 
which do not suppurate, claimed as sympathetic or scrofulous. Phage- 
denic buboes. All sores which give rise to suppurating buboes not 
necessarily chancroidal. Early treatment of gland swelling associated 
with chancroid. Calcium sulphide an efficient agent in arresting the 
suppurative process. Statistics in proof of this. Later treatment. 
Rest in bed important. Danger of extension of trouble through for- 
mation of sinuses. Signs of such accident. Treatment necessary to 
their arrest and subsequent cure. Chancroids of the anus and rectum. 
Usual mode of advent. Aids to diagnosis. Modes of treatment. 
Chancroids of anus and rectum. Mode of origin. Aids to diagnosis. 
Modifications of treatment to meet varied conditions. General reme- 
dial measures when local remedies prove inefficient. The exulcerous 
form of chancroid the mildest type. Mode of treatment. The ulcus 
elevatum not a true chancroid. Mode of treatment. Modifications re- 
sulting from the union of the contagia of chancre and chancroid. Syph- 
ilitic disease more likely to be associated with the milder forms of 
chancroid. Frequency of this accident. The term mixed chancre a 
misnomer. No mixing possible. Each disease always independent of 
the other, and always of necessity antagonistic. Possible development 
of the initial lesion of syphilis after the healing of a chancroid. 

Inflammation of lymphatic glands in connection with 
chancroid is not uncommon. The tumors, thus occur- 
ring, are termed chancroidal buboes. The inflammation 
is set up in such glands through the passage of the pus 
of the chanchroid through a lymphatic vessel. Inflam- 
mation is immmediately set up in the substance of the 
gland, which soon swells and becomes painful. Swel- 
ling of a lymphatic gland, from any cause, is usually 
called a bubo. Painful swelling of a lymphatic gland 
with inflammation, finally extending to the integument 
covering it, is termed an inflammatory bubo. When the 
inflammation is set up by inoculation, through the lym- 
phatic vessels in connection with chancroid, it is termed 
a chancroidal or virulent bubo. 

When an inoculation is thus effected, suppurative ac- 
tion is set up which (it has been taught as a rule to 



SYPHILIS AND THE GENITOURINARY DISEASES. 25 1 

which there is no exception) goes on to the formation 
of an abscess, and steadily progressing, in the course 
of two or three weeks, sometimes longer, finally finds 
its way through the parenchyma of the gland and the 
•overlying integument. When this is effected, the lesion 
is called an open chancroidal bubo, or a bubonic chan- 
croid. The purulent product of this lesion is, if not 
identical, analogous, in character, to that of the original 
chancroid. 

This accident may be initiated at any period in the 
course of the chancroid, from its first appearance as a 
small suppurative point, throughout its existence. This 
is a strong argument in favor of the early and thor- 
ough destruction of chancroid. The activity of the 
suppurative process in the gland, bears a tolerably defi- 
nite relation to that of the lesion from which it origi- 
nates. When the source of the pus is active, virulent, 
it is not probable that any course of treatment, local or 
general, will prevent its termination in open bubo or 
chancroid. Where glands, associated with chancroid, 
inflame and yet do not go on to formation of abscess, 
or when abscess is thus formed and its contents are ab- 
sorbed through treatment, local or general, it may be 
claimed that the chancroid, from which it is derived, 
is of mild type. It is, however, the habit of surgeons to 
classify all buboes (not syphilitic) which do not sup- 
purate, as sympathetic or scrofulous. 

Those resulting from irritation and not from inocula- 
tion, are termed sympathetic buboes. Whenever, 
through suppurative process, or by surgical intefer- 
ence, the chancroidal bubo is open, it goes on to ex- 
hibit the diagnostic appearances of the original chan- 
croid. Pus secreted by it, when inoculated at other 
points, or on another individual, produces the charac- 
teristic chancroid. 

When the lesion from which it is derived, assumes 
the phagedenic form, the danger of extension of phage- 
denic action, to the bubonic chancroid, is imminent. 
Phagedenic action may also be set up in a bubonic 
chancroid after the original chancroid has healed. In 
such case the treatment should be the same as that pre- 



252 PRACTICAL CLINICAL LESSONS ON 

viously directed (p. 244) for the phagedenic chanc- 
roid. 

The earlier the destruction of a chancroid is effected, 
the less the danger of a complication through medium 
of the connecting lymphatic vessels. This accident sel- 
dom affects more than a single gland, and that usually 
in the groin, corresponding to the side on which the 
chancroid is situated. Occasionally, however, through 
intercommunication of lymph canals, it may appear in 
the opposite groin, even in both groins. A sore of 
very mild type may give rise to a bubo which may go 
on to suppuration. All sores which give rise to abscess 
of lymph glands are not necessarily of chancroidal ori- 
gin. It is only by the activity of the contagium and of 
the inflammatory and destructive processes, exhibited 
in the inguinal lesion, that we can decide in what grade 
to place it. 

It is safe, at first, to treat all imflammatory gland 
swellings in connection with chancroid, as if they were 
of simple origin, that is, by rest in the recumbent posi- 
tion, by local sedative applications, and at once to begin 
the use of the sulphide of calcium internally, giving par- 
vules-j^ gr. every hour or two, or using a solution made 
fresh every day — 

5 Calx Sulphurata grs. 2. 

M. Aq 3 iv. 

A teaspoonful every hour or two. Also using pressure 
(when it is well borne), by means of a compressed 
sponge, retained by a spica bandage, and moistened 
with the lotto plumbi et opii. If pressure is productive 
of pain, and this continues after it has been on for a lit- 
tle time, cold applications, even the ice bag, will usu- 
ally give comfort, and, later, allow the pressure. If the 
feelings of the patient permit, the cold may be main- 
tained and in some cases abort the bubo. Tincture of 
iodine painted on morning and night is also valuable, 
if the patient cannot take the rest required for other 
treatment. It has the advantage of being easily kept 
in place, and the popular credit of favoring abortion 
where this is possible, and when this cannot be hoped 



SYPHILIS AND THE GENITO-URINARY DISEASES. 253 

for, of favoring suppuration. The early evacuation of 
the resulting abscess is usually advised. My habit, 
formerly, was to introduce a bistoury and make a free 
incision parallel to the long axis of the tumor at the 
earliest recognition of positive fluctuation. My later 
experience with the sulphide of calcium, administered 
internally, has caused me to delay operative interfer- 
ence until inefficiency of the sulphide of calcium has 
been fairly demonstrated.* 

Once the bubo has been laid open by an incision, ex- 
tending: through its long- diameter, it will be usually 
sufficient to pack the cavity with cotton or lint saturated 
with the ordinary tincture of iodine. This is a good 
styptic and has sufficient cauterant property to destroy 

* If suppuration, going on to the production of an open lesion, is in- 
evitable, undoubtedly it is wise to encourage it, to evacuate the virulent 
product at the earliest moment, and thus afford access for efficient treat- 
ment for the destruction of this new formed chancroid. For this reason 
I had been an earnest advocate for early incision into suppurating bu- 
boes associated with chancroid. My experience in the few cases above 
alluded to, however, made me incline to the belief that a thorough and 
extended trial of the sulphide of calcium, in cases of inflammatory buboes 
associated with chancroid, might give such results as to make its use 
imperative in every such case. 

In order to gain further light on this important matter, a systematic 
use of the calcium sulphide was made, in my service at Charity Hospi- 
tal, in eighteen consecutive cases of inflammatory bubo occuring with, 
or as the immediate sequel of, well-pronounced chancroid. All the facts, 
considered of importance, were noted by myself and under my direction 
by Dr. Johnson, my House Surgeon. 

Out of eighteen cases of inflammatory bubo presenting the rational 
evidences of chancroidal origin, and treated systematically by the use of 
small doses of the sulphide of calcium, resolution occurred in fifteen, 
and in only three cases was incision ultimately required. Applications 
of tincture of iodine and systematic compression were also employed 
in every case. 

If Ave apply to these cases the usual rule that chancroidal buboes al- 
ways eventuate in chanchroidal abscesses, always suppurate and require 
evacuation by natural means or surgical procedure, then we must hold 
that only three out of fifteen cases of inflammatory buboes associated 
with chancroid were the result of transference of the suppurative process 
from the chancroid to the adjacent lymphatic gland. It is just possible, 
however, that the influence of the sulphide of calcium may, in arresting 
suppuration, extend to the true chancroidal bubo. The apparent suc- 
cessful use of this drug in the series of cases herewith presented, at least 
suggests, and invites, a trial of its efficacy in all instances of threatened 
glandular suppuration, whether of purely sympathetic origin or asso- 
ciated with chancroid. 



254 PRACTICAL CLINICAL LESSONS ON 

the chancroidal contagium and stimulate the abscess 
cavity to healthy granulation. Iodoform may be sub- 
stituted if the iodine is objected to on account of pain ; 
the pain caused by it, however, is very commonly tran- 
sitory. Rest in bed is essential after the opening of the 
bubo, and until healing is well advanced, on account of 
the tendency to burrow, which abscesses in the region 
of the groin are wont to exhibit. The announcement 
of such an accident, is often, through a sharp rise of 
pulse and temperature, while the pain in the vicinity of 
the burrowing may be very slight. Whenever fever 
suddenly starts up in a patient suffering from an ingui- 
nal abscess or sinus, even when nearly healed, it is an 
almost certain sign of the formation or extension of a 
sinus, usually at the most dependent portion. In this 
event, after ascertaining its full extent by probing, in 
every case slip in a grooved director to the very bot- 
tom of the sinus, and if its direction is such as to make 
it surgically a proper thing to do, pass in a blunt curved 
bistoury and cut out — being careful not to leave a lit- 
tle pocket at the bottom. Injection of tincture of iodine 
may be made to advantage when cutting is not con- 
sidered feasible. For the same purpose, a silver probe, 
dipped in nitric acid, (which forms a coating of ni- 
trate of silver), may be conveniently applied by inser- 
tion of the probe. When possible, in cases where it is 
not considered judicious to lay it open throghout, the 
sinus should be drained by a counter opening, and, if 
suppuration is extensive, drainage effected by small 
perforated, rubber tubes, or carbolated threads. If not 
treated with promptness, extensive sinuses may form, 
requiring months to heal. 

DIAGNOSIS AND TREATMENT OF THE URETHRAL CHAN- 
CROID. 

A slight smarting on urination, or purulent discharge, 
appearing at the urethral orifice, six or eight days after 
impure connection, is suggestive chancroid of the mea- 
tus. Especially is a little blood in the discharge valu- 
able as a diagnostic point — careful examination should 






SYPHILIS AND THE GENITOURINARY DISEASES. 255 

be made at once. This form is quite common, and is 
usually slow in its progress. If the tissues at the lower 
part of the contracted orifice are very thin, as is often 
the case, snipping- them with a pair of blunt scissors 
will sometimes permit free application to the lesion 
without greatly increasing the surface thus exposed to 
inoculation, The use of a meatoscope, or a Toynbees 
ear speculum, will be of service in making examination 
and application beyond the orifice where, fortunately, 
chancroids are seldom met. If seen early, and the 
meatus is of sufficient size to expose it wholly, after 
cleansing with a weak carbolic lotion, and the part 
made properly dry, it should be thoroughly destroyed 
with nitric acid (after the manner described for small 
chancroids in other localities), subsequently dressing 
with a little thin linen wetted with a sedative lotion, or by 
small suppositories composed of equal parts of iodoform 
and cocoa butter. If the entire surface of the lesion 
cannot be exposed, treatment by iodoform suppositories 
will be best, using frequent hot water soakage, and in- 
sisting upon absolute rest. 

DIAGNOSIS AND TREATMENT OF CHANCROIDS OF THE 
ANUS AND RECTUM. 

These may occur as a result of connection a posteri- 
ori, or from inoculation. This accident, through chan- 
croids previously existing in the vicinity, is suggested 
by pain in defecation and purulent discharge. The in- 
troduction of the finger may be sufficient to make out 
a diagnosis, but the short rectal bivalve speculum, with 
narrow blades, will give access, when required, for 
diagnosis and treatment. But little especial treatment 
will be required, beyond that already suggested for 
other varieties. Cauterization to be made use of when 
called for ; and absolute cleanliness insisted on. 

If great difficulty and pain are experienced in intro- 
duction of necessary instruments and dressings, or if 
the lesion is penetrating the tissues rapidlv, or is rebel- 
lious to treatment, the external sphineter mav be divided 
through the lesion, and the cut surface treated, together 



256 PRACTICAL CLINICAL LESSONS ON 

with the chancroid, by application of iodoform and tan- 
nin suppositories, subsequently using nitric acid if nec- 
essary to arrest the disintegrating process, and then 
resuming the iodoform suppositories, until healing is 
complete. The use of the vaginal speculum, in treat- 
ing chancroid of the ostium vaginas and parts beyond, 
is absolutely essential, not alone for the security of 
reaching the full extent of the lesions, but for occasional 
examinations beyond the site of existing lesions, and 
to insure against insidious development of new points. 
The healthy tissues adjacent to contagious surfaces, 
should be kept constantly separate by thin layers of 
carbolated or iodoform dressing; and by occasional 
soakage in hot water, secure absolute cleanliness, and 
relief to inflammatory conditions. 

In all cases of chancroid, which, when judiciously 
cared for, are still rebellious to treatment — particularly 
those where ulcerations and sinuses have occurred, the 
general condition of the patient should receive especial 
attention. In cases of scrofulous habit, cod liver oil, 
iron, etc., are often of service in hastening the healing of 
a sluggish chancroid. The case cited page 223, where 
all measures failed, until a change of climate and a sea 
voyage wrought a prompt cure, is significant. 

The Exulcerous Form of Chancroid, described 
as existing without perceptible loss of tissue, being 
either on a level or slightly above the surrounding sur- 
face, and hence not characterized by the usual marks of 
chancroidal action — must be classed as of the mildest 
form, and amenable usually to local astringent sedative 
applications. The sulphate of iron as a lotion — 10 grs. 
to § 1 of water — is often promptly curative. 

The Ulcus Elevatum, a lesion of the same type, is 
scarcely to be classed among chancroids, as it lacks 
wholly the characteristic features of such lesions. It is 
usually not larger than a flattened pea, and found on 
the borders of a prepuce, which is bathed in secretions 
more or less vitiated. It partakes more of the nature 
of a papilliary hypertrophy, and a local treatment adapt- 
ed to such overgrowth should be employed, viz. : re- 
moving first the source of the irritant secretion, then 



SYPHILIS AND THE GENITO-URINARY DISEASES. 257 

apply the powdered persulphate of iron, or if necessary, 
to touch, lightly, with pure chromic acid. 

MODIFICATIONS RESULTING FROM DEVELOPMENT OF 
SYPHILITIC ELEMENTS, IMPLANTED ON THE SITE OF 
A CHANCROIDAL LESION. 

The milder the form of chancroid, the more likely to 
develop a syphilitic complication, after syphilitic ex- 
posure. Active chancroidal action, is doubtless as de- 
structive of the syphilitic contagium, as of healthy tis- 
sue, but when, as is sometimes the case, the contagia of 
both chancre and chancroid are implanted on the same 
abrasion, at about the same time, the chances are, that 
the syphilitic disease germ, will find its way into a 
lymph space, and out of the reach of harm, before con- 
tact with the destructive chancroidal cell. This latter, 
going steadily on in its characteristic destructive action, 
while the proliferation of the syphilitic disease germs is 
progressing underneath. So it often happens, that, 
while the chancroid is in full typical action, the tissues 
underlying and surrounding, become gradually stiffened 
and indurated, until a sore presents, equally character- 
istic of both chancroid and the initial lesion of syphilis. 
This is known as the " mixed chancre." 

It will be at once seen that there is not, and never 
can be, any mixing of the contagion of chancroid and 
syphilis, one representing the destruction and the other 
the growth of tissue elements. Necessity for the treat- 
ment of the chancroid, is the same as before, but the 
complication requires the constitutional treatment ap- 
propriate for syphilis, at the first moment, when, 
through development of other characteristic syphilitic 
lesions, the diagnosis can be definitely settled. The 
development of induration of syphilis, after the healing 
of a chancroid (the tissues about which have remained 
supple throughout its existence) is also not uncommon, 
The possibility of such an occurrence must be borne 
prominently in mind, for several weeks after the heal- 
ing of any lesion resulting from a suspicious sexual 
contact. 



258 PRACTICAL CLINICAL LESSONS. 



Remedies and Remedial Agents Referred to in this Volume, and 
their Application. 

For Local Application to the Initial Lesion of Syphilis. 

In the non-ulcerative forms; the indurated papule, and the dry scaling 
patch. 

No. 1. White precipitate ointment, vaseline; equal parts; or, 

No. 2. The mild mercural ointment; or, 

No. 3. The oleate of mercury, 6 per cent solution, with vaseline; 
equal parts. 

Apply by gently rubbing in a small quantity morning and night. 

In all Uncomplicated Open Initial Lesions. 

No. 4. Calomel pure, dusted on and protected by a thin film of bor- 
ated cotton; or soaking the cotton with the following solution, and 
apply; or, 

No. 5. Calomel, 20 grs. ; lime water, 4 ounces; mix; or, 

No. 6. Corrosive sublimate, 10 grs. ; lime water, 6 ounces; mix. 

For the Inflamed Initial Lesion. 

Diluted solution of sub-acetate of lead, 4 ounces. 
No. 7. Aqueous ext. opium, 10 grs.; or, 

No. 8. Iodoform, 30 grs.; glycerine, 1 ounce; oil of roses, 1 drop; 
mix; apply on lint. 

For the Phagedenic or Gangrenous Form. 

No. 9. Iodoform, a sufficient quantity; 1 drop of the oil of roses to 30 
grs. ; applied freely. 

Internal Remedies for Treatment of Syphilis, from date of 
Initiation, for at least 12 Months. 

No. 10. Blue mass., 60 grs.; exsicated sulphate of iron, 30 grs. ; make 
30 pills (pil. duplex), one three times a day; or, 

No. 11. Protoiodide of mercury, exsicated sulphate of iron, 40 grs.; 
aqueous extract of opium, 4 grs.; mix, make 40 pills; one three times a 
day. 

External Applications for Innunction. 

No. 12. The mild mercurial ointment; a piece as large as a filbert 
rubbed in thoroughly, morning and night; or, 

No. 13. Oleate of mercury, 10 per cent solution; vaseline an equal 
quantity; a teaspoonful rubbed in, morning and night, always in a fresh 
and protected place. 

For Mercurial Fumigation, or the Mercurial Bath. 

No. 14. Calomel, (resublimed) 15 to 30 grs.; nightly, or every two or 
three nights, until its specific effect is obtained. Further directions on 
page. 



SYPHILIS AND THE GENITOURINARY DISEASES. 259 

After the Twelfth Month, the Mixture of the Biniodide 
of Mercury and the Iodide of Potassium. 

No. 15. Biniodide of mercury, 3 grs. ; iodide of potassium, 120 grs. ; 
tincture of orange peel, i-J ounces; syrup of orange peel, i-£ ounces; 
distilled water, up to 8 ounces; mix; a teaspoonful three times a day, or 
if gastric or intestinal irritation ensues — 

No. 16. Biniodide of mercury, 3 grs.; iodide of potassium, 120 grs.; 
fluid extract of thuja, 8 ounces; mix; a teaspoonful three times a day. 

In addition to the foregoing, 

During the Sequels of Syphilis. 

No. 17. Iodide of potassium, 1 ounce; distilled water, 6 drams; mix. 
Beginning with 5 drops in a small glass of water, or preferably of milk, 
increasing by a drop for each dose, gradually increasing the diluent to a 
tumblerful, until sixty drops are taken, equivalent to 60 grains of the 
iodide of potassium, three times daily, after meals, unless iodism occurs. 
In this case begin again with the minimum dose, and increase as before 
up to 40 drops, and then increase by I drop, until 60 grains is again 
reached. If decided benefit does not take place, the quantity may be 
even farther increased up to twice that amount, in grave cases, and con- 
tinued, if well borne, until all signs of the disease have disappeared. 

If the iodide of potassium is not tolerated, the following may be 
administered. 

No. 18. Iodine, 24 grains; distilled water, 2 ounces; iodine of potas- 
sium, 48 grains; dissolve and add common molasses, or Stuart's syrup, 
8 ounces; let it stand 12 hours. Administer from a dessertspoonful, 
gradually increased to a tablespoonful, thrice daily after meals. 

In the Alopecia of Syphilis. 

The following lotions will be found serviceable: 

No. 19 Bi-chloride of mercury, 3 grains; hydrochloric acid, 30 min- 
ims; distilled water, 8 ounces; then add, spirits of cologne, 1 ounce; 
rose water, 1 ounce; glycerine, ■$■ ounce; mix; or 

No. 20. Castor oil, i£ ounces; rectified spirit, i-£ ounces; spirits of 
cologne, 1 ounce; tincture of cantharides, 2 drams; mix, apply nightly, 
washing the hair every morning with castile soap. 

For Local Applications in the Treatment of Chancroid in the 
Slowly Destructive Forms. 

No. 21. Sulphate of iron, 10 grains; aqueous extract of opium, 10 

grains; distilled water to 1 ounce. 

No. 22. Carbolic acid, 5 to 10 grains; solution of morphia, (U. S. P., 

containing 1 grain of morphia), 1 ounce. If the secretion is profuse, 
No. 23. Iodoform and tannic acid, equal parts, dusted on; mix; in the 

more acute forms, 

No. 24. Iodoform, 60 grains ; vaseline, 60 grains ; oil of roses, 1 drop ; or, 
No. 25. Iodoform, 60 grains; oil of roses, 1 drop; apply in powder; or, 
No. 26. Iodoform, 1 dram; carbolic acid, 1 minim; oil of peppermint, 

6 minims; mix. 



260 PRACTICAL CLINICAL LESSONS. 

For Destruction of the Chancroid, or Phagedenic Conditions. 

Nitric acid, pure; galvano cautery, or the thermo cautery. 

For Sluggish Conditions. 

No. 27. Permanganate of potassa, 2 grains; distilled water, 1 ounce. 
No. 28. Carbolic acid, pure; applied daily; or, 

No. 29. Carbolic acid, 10 grains; glycerine, 2 drams; distilled water, 
6 drams; mix; apply on a thin film of cotton. 

For Application to Bubonic Ulcers, and Sinuses. 

No. 30. Tincture of iodine, pure; and, for arrest of suppuration in any 
case. 

No. 31. Sulphate of calcium, I grain; distilled water, 2 ounces; a tea 
spoonful every hour, solution to be freshly made every day; or, 

Parvules, y^ grs. each. 

For Applications to the Phagedenic Chancroid. 

No. 32. Hot water immersion, temperature 100 F. ; actual cautery; 
charcoal poultices 

Internally, (Ricords formula). 

No. 33. Potassio tartrate of iron, \ ounce; distilled water, 3 ounces; 
syrup. 3 ounces; mix; a dessertspoonful to a tablespoonful three every 
six hours, preferably after meals. 



CONTENTS. 



LESSON XXXI. PAGE 

Nature of Gonorrhoea 261 

LESSON XXXII. 
Diagnosis of Gonorrhoea 271 

LESSON XXXIII. 
Treatment of Gonorrhoea 282 

LESSON XXXIV. 
Treatment of Gonorrhoea — {Continued) 291 

LESSON XXXV. 
Treatment of Gonorrhoea — {Continued) 300 

LESSON XXXVI. 
Treatment of Gonorrhoea — {Continued) 302 

LESSON XXXVII. 
Treatment of Gonorrhoea — {Continued) 311 

LESSON XXXVIII. 
Treatment of Gonorrhoea — {Continued) 317 

LESSON XXXIX. 
Injections in Gonorrhoea — Gleet 330 



IV CONTENTS. 

LESSON XL. PAGE 

Nature of Gleet 336 

LESSON XLI. 
Dependence of Gleet upon Stricture 346 

LESSON XLII. 
Complications of Gonorrhoea 353 

LESSON XLIII. 

Folliculitis— Follicular Ulceration — Urinary Infiltration — External 
Perineal Urethrotomy ... 366 

LESSON XLIV. 
Urinary Extravasation 373 

LESSON XLV. 

Follicular Sinuses Associated with Urethral Contractions and Reflex 
, Neuralgia 380 

LESSON XLVI. 
Epididymitis 390 

LESSON XLVII. 
Prostatitis 402 

LESSON XLVIII. 
Acute Prostatitis — {Continued) 405 

LESSON XLIX. 
Cystitis 413 

LESSON L. 
Urethral Stricture 4*8 

LESSON LI. 
Cause of Stricture 426 



CONTENTS. V 

LESSON LII. page 

Examination of the Urethra 439 

LESSON LIII. 
Urethrotomy 446 

LESSON LIV. 
Dilating Urethrotomy 457 

LESSON LV. 
Dilating Urethrotomy — {Continued) 463 

LESSON LVI. 
Spasmodic Stricture, or Urethrismus 470 

LESSON LVII. 
Reflex Irritations throughout the Genito-Urinary Tract 487 

LESSON LVIII. 
Clinical Cases in Illustration of Reflex Irritations 493 

LESSON LIX. 
Clinical Cases in Illustration of Reflex Irritations — (Continued) 499 

LESSON LX. 

Chronic Irritation of Bladder — Neuralgia of Testicles — Irritation of 
Glans — Lack of Virility 505 

LESSON LXI. 
Clinical Cases 512 

LESSON LXIL 
Clinical Cases — {Continued) — Urethrismus. 5i9 

LESSON LXIII. 
Chronic Spasmodic Stricture 526 



VI CONTENTS. 

LESSON LXIV. PAGE 

Urethrismus, or Chronic Spasmodic Stricture — {Continued) 538 

LESSON LXV. 
Persistent Recurring Reflex Spasm of the Bladder 541 

LESSON LXVI. 
Spasmodic Stricture Simulating Prostatic Enlargement 550 

LESSON LXVII. 

Digital Exploration of the Bladder, as an Aid to Diagnosis in Ob- 
scure Cases 564. 

LESSON LXVIII. 

Digital Exploration of the Bladder, as an Aid to Diagnosis in Ob- 
scure Cases — (Continued) 572 



GONORRH(EA AND ITS SEQUELS. 



LESSON XXXI. 

GONORRHOEA. 

Nature of gonorrhoea — Its usual seat — May be transferred to the mucous 
membrane of the eye, and to other points, through mediate contagion 
— Gonorrhceal ophthalmia a very grave accident — Gonorrhoea a non- 
. specific disease, and may be set up by a variety of causes, although 
usually the result of venereal contact — Cases in illustration — Gonor- 
rhoea identical with non-specific infantile leucorrhcea — Cases in illus- 
tration — Case showing how the origin of gonorrhoea may become 
important in a medico-legal point of view — Gonorrhoea induced by 
injections — Case in illustration — Gonorrhoea induced by urethral 
stricture — Case in illustration — Nature and composition of mucous 
membrane — Manner in which its secretion is elaborated — Manner in 
which the normal secretions are changed to a purulent discharge — 
Beale's view of disease-germs in gonorrhoea — Varieties in the severity 
of gonorrhoea — Case in illustration. 

We enter now upon a consideration of the third, and 
last, in the list of veneral diseases alluded to, in the open- 
ing lecture of our course, viz.: 

Gonorrhoea. — This is a vicious, non-specific, conta- 
gious, inflammatory disease of the mucous membranes, 
and is usually acquired through contact in the venereal 
act. 

It is characterized by free purulent secretion, without 
ulceration, occurring chiefly in the mucous membrane 
lining the urethra in the male, and the vagina and ure- 
thra in the female ; and occurring exceptionally, in the 
mucous membrane of the rectum. 



262 GONORRHOEA AND ITS SEQUELS. 

By transference from these points, the disease may 
be conveyed to the mucous membrane of the eye. 

The occurrence of conjunctival gonorrhoea, is by 
means of mediate contagion ; that is to say, by the ap- 
plication of the poison through some intermediate sub- 
stance, as the fingers, sponges, cloths, etc. This is one 
of the gravest accidents that can occur in consequence 
of gonorrhceal affection. 

The transfer of the disease, in the same manner, to the 
nares and to the mouth, is alluded to by authors, but I 
have never seen such cases, and believe they are so rare 
that, practically, we need not give them much consider- 
ation. 

This disease is termed vicious, on account of the acute- 
ness of its onset, as compared with idiopathic or trau- 
matic inflammation of mucous membrane, and from the 
greater disturbance, local and general, which marks its 
course. 

It is termed non-specific, because it is capable of 
being originated by a variety of causes quite indepen- 
dent of a gonorrhceal origin, and even of the venereal 
act. 

This is an important statement, but one which is 
capable of thorough substantiation by clinical proof, 
as will be shown hereafter. It is, however, as a matter 
of course, denied by those claiming a specific venereal 
virus as the essential, the one sole efficient agent, in the 
establishment of a true gonorrhoea. 

The disease is called contagious, and inflammatory, be- 
cause pus, the product of this variety of inflammation, 
when brought in contact with sound mucous membrane, 
sets up in it, at once, an inflammatory process of a similar 
character. 

While usually communicated through illegitimate 
venereal contact, yet a similar inflammation of mucous 
membrane, producing pus which possesses equally the 
element of contagion, may arise from causes purely in- 
flammatory. Thus, mechanical irritation, caused pos- 
sibly by the introduction of a urethral sound, may set 
up inflammation producing a purulent secretion, which, 
when brought in contact with healthy mucous mem- 



GONORRHOEA AND ITS SEQUELAE. 263 

brane, will develop a disease, in no respect different 
from acute gonorrhoea, the result of venereal conta- 
gion. 

Allow me to relate a case which bears upon this point. 
Some four years ago, a gentleman came to me, suffering 
from irritation at the neck of the bladder, as evidenced 
by discomfort in that region, and also a certain amount 
of irritation in the glans penis. He was a man entirely 
above suspicion of illegitimate venereal indulgence. He 
was under my direct observation, for at least four or 
five months, before I came to the conclusion that his 
difficulty was dependent upon the influence of a con- 
tracted meatus urinarius. I had already made a thor- 
ough examination with reference to the presence of 
stone in the bladder and prostatic enlargement, and 
found neither. I incised the meatus so that the contrac- 
tion was completely removed, and with it immediately, 
to my great satisfaction, the frequency of micturition 
ceased, and all sense of discomfort disappeared. The 
only after-treatment necessary was in keeping the open- 
ing patent. An ordinary sound was introduced some 
four or five times. The case was doing very well. But 
the gentleman had a large business to look after, and, 
finding it exceedingly inconvenient to come to my office, 
begged the privilege of using the sound himself. I 
objected, and yet yielded to his wishes, inasmuch as I 
did not see why he should not be able to perform the 
operation, if a reasonable amount of care was exer- 
cised. I gave him a new instrument, a solid glass rod of 
proper size and shape, and directed him to pass it well 
through the meatus every morning, and to do it care- 
fully. 

At the end of about a week, he came to me with his 
penis considerably swollen and inflamed. A slight 
muco-purulent discharge was exuding from the mea- 
tus. 

In reply to my inquiry, he stated that he found some 
difficulty in introducing the instrument, that this in- 
creased daily, until finally, " determined not to be beaten 
by it," he had carried it in with some degree of violence. 
The condition which his penis presented was the result. 



264 GONORRHCEA AND ITS SEQUELS. 

Nothing could be more certain, than that this inflamma- 
tion was the result of mechanical violence. The inflam- 
matory action increased and extended, as in an ordinary 
gonorrhoea resulting from an impure venereal contact, 
and finally involved the deeper portions of the urethra. 
He was even threatened with prostatic abscess, but 
after confinement in bed, at least four or five weeks, he 
recovered with slight remaining discharge. This dis- 
charge continued for some time; it was exceedingly 
slight. Thus far the case would have been placed under 
the head of ordinary simple urethritis, which by many 
is considered as entirely different from gonorrhceal ure- 
thritis, and especially so as lacking the element of con- 
tagion. 

During the summer, the discharge from the meatus 
disappeared almost entirely, and, under the impres- 
sion that there was no danger of communicating his 
disease, he had a single connection with his wife. 

About two weeks after, the wife came to me, suffer- 
ing with a well-marked, acute vaginitis which had ex- 
tended to the urethra. She was a lady over fifty 
years of age, and entirely above reproach. To my 
mind, there was no doubt whatever but that she ac- 
quired the disease from her husband, whose disease 
was of traumatic origin. The result of this intercourse 
was a disease which could not be distinguished from 
that which is acquired from a known gonorrhoea. I 
have, besides, seen several cases which, equally with 
the one now related, go to prove that a contagious 
secretion from mucous membrane may be present, as 
the result of simple causes, wholly independent of con- 
tagion. 



GONORRHCEA IDENTICAL WITH INFANTILE LEUCOR- 

RHGEA. 

Another cause of the inflammation of mucous mem- 
brane, which does not vary in any practical degree from 
gonorrhceal inflammation, is infantile leucorrhoea. This 
is recognized by all authorities as a contagious disease 



GONORRHCEA AND ITS SEQUELAE. 265 

of the mucous membrane. A similar vaginitis may be 
communicated from it to other children, when the same 
sponges or bathing-cloths are used, and an ophthalmia 
is not rarely set up by means of it, which cannot be dis- 
tinguished from true gonorrheal ophthalmia. 

This form of leucorrhcea is caused, as generally be- 
lieved, by irritation in a contiguous organ, the rectum. 
It has also been attributed to the irritation produced 
by teething. But, whatever the cause may be, an in- 
flammation is set up in the vagina of the infant, which 
produces a discharge that cannot be distinguished from 
a gonorrhceal discharge, and which may communicate 
a similar disease. 

Some time since a lady called upon me, accompanied 
by her little daughter (between nine and ten years old). 
She stated that the child was suffering from a bad dis- 
order, which she believed had been communicated by a 
young man, intimate in the family, who had been in the 
habit of playing with the little girl. The visit to me 
was for the double purpose of obtaining relief for the 
child and securing some advice as to the way of pun- 
ishing the young man. On examination, the vulva was 
seen intensely reddened, and bathed in a profuse, green- 
ish purulent discharge. The hymen was perfect, with 
no sign of injury. The integument around the anus 
was irritated, as if by scratching, and great itchiness in 
vicinity was complained of. The rectum was found 
loaded with ascarides. The cause of the leucorrhcea 
was thus satisfactorily explained without implicating 
the young man. Suppose, however, the youth had been 
subjected to an examination, and had chanced to have 
an old gonorrhoea ; the probabilities would have been 
greatly against his being able to establish his innocence 
before any jury. 

Here we see that the question, as to the specific char- 
acter of gonorrhoea, may become of first importance, 
from a medico-legal point of view. 

In support of the practical identity of irritative in- 
fantile leucorrhcea and venereal gonorrhoea : Not very 
long since a case somewhat similar was reported to the 
Medical and Surgical Society by Dr. Robert Watts. In 



266 GONORRHOEA AND ITS SEQUELAE. 

a very respectable family of children, one of the little 
girls was afflicted with a leucorrhcea similar in its origin 
and characteristics to the case previously described. 
The physician in charge directed the use of applications 
by means of a bit of soft sponge. Within a few days a 
little son only three years old began to show signs of 
inflammation of the preputial orifice. It was found that 
the same sponge used on the little girl had been used 
in washing the little boy. An acute purulent discharge 
soon appeared, issuing from the prepuce, which, at first, 
was supposed to be only a balanitis. At about the 
third week, however, one of the testicles became ten- 
der, and swollen, and apparently passed through all the 
stages of an epididymitis, similar to that following ordi- 
nary gonorrhoea. 



GONORRHOEA PRODUCED BY INJECTIONS. 

During my term of service as Resident Physician on 
Blackwell's Island, over 30 years ago, several experi- 
ments were made, with reference to the question of the 
causation of gonorrhoea by other means than by contact 
with gonorrhceal discharge. At the instance of Dr. 
William Kelly, then Physician-in-Chief, various irritating 
materials, including pus from various sources; were in- 
jected into the urethra of healthy individuals, but with- 
out satisfactory results, so far as producing gonorrhoea 
was concerned. Finally, the experiment was made with 
pus, taken from the eye of a child, suffering from acute 
ophthalmia, and a virulent gonorrhoea was established, 
which continued for four or five weeks, and was at- 
tended by the ordinary complications of gonorrhoea, 
oedema, chordee, etc. Here the disease was produced 
by causes entirely independent of gonorrhoea! contact. 
As far as could be ascertained, the trouble with the child 
was free from suspicion of gonorrhceal origin. It is 
shown by the above mentioned experiments, that pus of 
an unusually high grade of activity, is necessary to set 
up a true gonorrhoea. 



GONORRHOEA AND ITS SEQUELAE. 26j 

GONORRHOEA PRODUCED BY THE DISCHARGE ACCOM- 
PANYING STRICTURE. 

There is still another cause of gonorrhoea that must 
be mentioned, in order to make this part of our subject 
complete. 

It is a very important fact, that a discharge, which 
does not at all differ from true gonorrhoea, may arise 
through contact with the discharge produced by me- 
chanical irritation incident to stricture of the urethra. 

A man who has a stricture, but has had no discharge 
whatever from the urethra for several years, is suddenly 
placed in circumstances under which an unusual amount 
of excitement is present in the circulation of that local- 
ity ; for example, he gets married. A few days after 
marriage — and I am not now drawing upon general 
experience or imagination, for I am relating the history 
of a real case — the man discovers that he has a discharge 
from the urethra, precisely similar to one of his early 
gonorrhoeas. Naturally enough, he does not asso- 
ciate the presence of the discharge, with the fact 
that he had disreputable connection, followed by dis- 
ease, some years previously. The only explanation 
which seems possible is, that it has been contracted 
from his bride. He becomes greatly excited, but be- 
fore openly disgracing the apparent criminal, he goes 
to his physician to secure a trustworthy witness of her 
guilt. The physician, however, knowing of certain 
wild oats sown in earlier life, tells him to pause before 
he concludes that his wife has been unvirtuous. An 
examination is made, and unmistakable evidence of stric- 
ture is found. The conclusion is readily reached that 
it had been in existence for some time. This becoming 
appreciated as sufficient cause of the trouble, the man 
at once gives up all suspicion regarding the impurity of 
his wife. 

Within a few days, however, the wife begins to com- 
plain, and very soon has a sharp attack of vaginitis, and 
then comes her turn to enter complaint. The discord, 
however, is finally harmonized through an understand- 
ing that the original difficulty with the husband had 



268 GONORRHOEA AND ITS SEQUELAE. 

been acquired several years before. The fact which I 
wish to make clear is this : that by excess of drinking, 
sexual intercourse, mechanical irritation, etc., a simple 
purulent discharge may be elevated to the point of 
contagiousness; that when raised up to that point it 
is no longer simple, and will communicate gonorrhoea 
when brought in contact with healthy mucous mem- 
brane. 

INFLAMMATION OF MUCOUS MEMBRANE. 

Before proceeding further with our subject, it will 
perhaps be interesting to study the subject of inflamma- 
tion of mucous membranes somewhat in detail. 

Mucous membrane is made up of several layers : the 
uppermost or epithelial, the basement membrane, and 
the areolar tissue layer. In the mucous membrane of 
the urethra, the epithelium is chiefly in the form of 
liminated scales, and the secretion which is associated 
with it, is the result of the gradual development of this 
scaly layer. Formative germinal cells come up through 
the basement membrane, laden with germinal juices, 
which, as the cell develops into the epithelial scale, 
exude and lubricate the canal, thus protecting it from 
the action of the acrid secretions that pass over its sur- 
face. This is the natural process by which the fluid, that 
is necessary for lubrication, is obtained, and the quan- 
tity, in health, is never sufficient to constitute a discharge. 
Any discharge from the urethral mucous membrane is 
pathological, with a single exception, and this is the slight 
transparent exudation from the mucous glands which 
comes on through venereal excitement. In the normal 
development of the epithelial layers, there is just enough 
material furnished, for the gradual development of the 
germinal cell into the complete epithelial scale. But set 
up an irritation, and nature responds to such irritation, by 
sending up an excessive supply of " pabulum." The upper 
layers of cells are detached with greater rapidity than in 
health, an increased quantity of mucoid or lubricating ma- 
terial is thrown out, and we then have the first signal 
that a pathological process is coming on. This process 






GONORRHOEA AND ITS SEQUELAE. 269 

continues, and within a short time the undeveloped 
germinal cells appear upon the surface of the mucous 
membrane as a discharge. If you examine a urethral 
secretion when inflammation is present, you will find 
it to consist largely of cells, which, to all appearances, 
are the same as the white blood-corpuscles. They are 
not normal white blood-corpuscles, however, but cells 
which have been emasculated by too rapid development. 
They retain the power of proliferation and movement, 
but they are incapable of elevation into useful tissue, 
and finally emerge from the urethra as a discharge that 
is called pus. These cells may appear in such quanti- 
ties that we see them as a profuse discharge, and, in the 
highest stage of the inflammation, this discharge has a 
greenish color, which indicates the additional presence 
of red blood-corpuscles. 

Beale says, that, when this inflammatory process has 
gone on for a little time, a kind of proliferation of cells 
takes place upon the surface, in addition to those which 
come up from the tissues beneath, and that the rapid 
disintegration of material produced in this manner, gives 
rise to the infective element of the discharge. Cells 
thus proliferated, constitute what he terms disease 
germs, and he claims that they may be produced in this 
way : that they retain life with great tenacity, and may 
be carried for a long distance, and yet when brought 
in contact with a healthy mucous membrane, will set 
up an inflammation, of like character as that from which 
it originated. Whether this view is correct or not, 
we have sufficient knowledge to state that pus, under 
certain circumstances, becomes highly irritant and con- 
tagious ; that a mild form of inflammatory product, 
may become changed to that which is contagious. The 
theory above advanced would certainly explain the con- 
tagious character of the gonorrhoea, and also the differ- 
ent varieties of the disease with which we meet. 

You will remember, that last week, a man came before 
us, who had a profuse purulent discharge from the ure- 
thra. That discharge was acquired, through venereal 
contact, about five or six days before his visit here. 

On questioning him, it was found that he did not suf- 



270 GONORRHCEA AND ITS SEQUELS. 

fer from pain at all, and that except for the discharge, 
he was not able to say there was anything the matter 
with him. At the time, I called your attention to the 
fact, that it was one of the milder varieties of gonorrhoea. 
There was, perhaps, no question regarding the origin 
of the disease, and yet I doubt very much whether that 
discharge would, if placed in contact with healthy mu- 
cous membrane, have communicated gonorrhoea. The 
grade of inflammation was low, and so low, that it is a 
question whether its products were capable of estab- 
lishing an inflammation of like character. But let such 
a man go on a drunken spree, or have excessive sexual 
intercourse, you would find that his discharge would 
become painful. If, then, it was brought in contact 
with healthy mucous membrane, you would see de- 
veloped a corresponding discharge, and an active con- 
tagious property would be present. There are, there- 
fore, two varieties of the affection: 1. That in which 
there is a slight, painless, purulent secretion. 2. That 
in which a higher degree of inflammatory action is 
present, which gives rise to pain and a greenish puru- 
lent discharge. 

A man may come to you, complaining of an almost 
white purulent discharge, and at the same time saying 
that the connection had been with a woman whom he 
knew to be free from gonorrhoea. Perhaps the addi- 
tional statement will be made, that she was suffering 
from the " whites," or that she had just completed her 
menstrual period. If you do not interfere with the dis- 
charge, it will disappear within four or five days, as a 
rule, and the man will be well. But the trouble is that, 
as soon as a man sees a drop of pus at the meatus uri- 
narius, he goes to a doctor, who attempts, in very many 
cases at least, to abort the gonorrhoea. A solution of 
nitrate of silver is employed as an injection, and if that 
is kept up for four or five days, a sharp urethritis is 
usually established. I do not believe there is any such 
thing as aborting true gonorrhoea. Gonorrhoea runs 
its course, and lasts about four weeks, and any urethral 
discharge that exists for a less period, I should be. will- 
ing to say was not gonorrhoea. 






GONORRHOEA AND ITS SEQUELS. 27 1 



LESSON XXXII. 

Specific origin of gonorrhoea still claimed — This claim opposed by both 
early and recent accepted authorities — Arguments advanced in favor 
of its non-specific origin — Necessity of the understanding of physio- 
logical processes to settle the question — Claims of a specific origin of 
gonorrhoea through a micrococcus — Arguments to prove this a fallacy — 
Differential diagnosis — Urethral stricture a cause of discharge which 
may be mistaken for a gonorrhoea — Abortive treatment of gonorrhoea 
not warranted by experience — No well-authenticated case of the suc- 
cess of such treatment yet produced — Gonorrhoea acquired from a well- 
authenticated gonorrhoea not susceptible of speedy cure. 

The importance of a clear appreciation of the nature 
of gonorrhoea, warrants me in again calling your atten- 
tion to this subject. Is it, as I have positively claimed, 
a non-specific disease — that is to say, one capable of 
being originated, in typical form, through a variety of 
causes, or must it always and invariably be referred to 
contact with the secretion of a pre-existing gonorrhoea? 
I need not assure you that I have no doubt, personally, 
that this is a fact. The reasons for believing the disease 
a non-specific one, and some of the cases proving it, have 
been laid before you in a previous lesson. But, I gave 
you simply the results of my own thought and expe- 
rience. I did not say to you that a contrary view is still 
held and taught. This is so prominent a fact, that it 
appears to me desirable, to present to you some of the 
reasons given, for belief in the specific origin of gonor- 
rhoea, and also to support my own views by citations 
from eminent contemporary authorities. 

In the year 1877, a prominent English surgeon issued 
a book, confined to the subject of gonorrhoea alone, and 
containing about 400 pages. Its author is a gentleman 
who has been identified with the study and treatment of 
genito-urinary diseases in England for many years, and 
I can commend this book to you as the most valuable 
and comprehensive work on this subject in our language. 
But, in it, Mr. Milton has raised some issues which I 



272 GONORRHCEA AND ITS SEQUELS. 

thought were settled ; especially that most important 
one with reference to the specific character of gonorrhoea. 
After considering the question, as it would seem, quite 
thoroughly, the author arrives at a conclusion which, to 
me at least, is extraordinary, which is that, so far as he 
is able to judge, gonorrhoea is the result of gonorrhoea only. 
Now, the French authorities, of which Ricord is the 
leading representative, almost without exception make 
the definite and unequivocal statement, that true gonor- 
rhoea may be acquired from a simple leucorrhcea. 
Ricord gives repeated instances of this kind, and also 
cites examples in which a gonorrhoea, not distinguishable 
from that acquired by contagion, has been produced 
solely by a persistent and continued ungratified venereal 
excitement. 

In this country we have Drs. Bumstead and Taylor 
(favorably known as authorities in this department) con- 
firming this view on page 40 of their work (ed. 1879), as 
follows : Dr. B. says, " I have been convinced, by some- 
what extended observation, that gonorrhoea originating 
in this mode, is of very frequent occurrence. Of one 
thing I am absolutely certain, that gonorrhoea in the male 
may proceed from intercourse with a woman, with whom 
coitus has for months, or even years, been practised with 
safety, and this, too, without any change in the condition 
of her genital organs, perceptible upon the most minute 
examination with the speculum. I am constantly meet- 
ing with cases, in which one or more men have cohabited 
with impunity with a woman, both before and after the 
time when she has occasioned gonorrhoea in another 
person ; or, less frequently, in which the same man, after 
visiting a woman for a long period with safety, is 
attacked with gonorrhoea, without any disease appear- 
ing in her, and after recovery, resuming his intercourse 
with her, and experiences no further trouble. The 
frequency of such cases, leaves no doubt in my mind, 
that gonorrhoea is often due to accidefital causes and not to 
direct contagion" And page 41, " Most cases of gonor. 
rhceafrom leucorrhcea, or the menstrual fluid, present no 
characteristic symptoms by which they can be distin- 
guished from those originating in contagion. " Drs. 



GONORRHOEA AND ITS SEQUELAE. 273 

Van Buren and Keyes (who have written an excellent 
work upon genito-urinary diseases), express themselves 
with the greatest positiveness on this point, on page 
53 : * " Experience proves beyond a doubt that a high 
condition of urethral inflammation, attended by an 
abundant discharge, and presenting absolutely no 
features to differentiate it from a gonorrhoea derived 
from a prostitute with a virulent discharge, may be 
acquired by a young lover, from his equally healthy 
mistress, by a young husband from his wife, or may be 
produced by applying a chemical irritant to the ure- 
thra." 

Dr. Fordyce Barker, of this city, quoted by Dr. 
Bumstead (Bumstead and Taylor, page 41), speaks of a 
peculiar form of metritis, which has associated with it, a 
leucorrhceal discharge, that, in repeated instances, has 
produced a purulent urethritis in the male. Not long 
since, a gentleman came into my office, with the state- 
ment that he had been married nearly one year; that 
shortly after marriage a purulent discharge came from 
his urethra. On consultation with his physician he was 
told it was of slight importance, and had probably been 
acquired from a leucorrhceal trouble from which his 
wife was then suffering. From that time, within three 
or four days after each sexual congress with his wife, a 
purulent discharge appeared in his urethra and con- 
tinued until assisted by an astringent injection. When 
examined, the man was found to be free from any trouble 
whatever. Upon examining the wife it was ascertained 
that she was suffering from retroversion of the uterus ; 
that the surface of the external os was eroded and 
covered with a thin layer of muco-purulent material. 
The uterus was restored to its normal position and re- 
tained by a pessary. I was of the opinion at the time 
that the erosion and discharge were due to displacement 
of the uterus, and so stated. Under suitable treatment 
the lady made a prompt recovery, and from that time 
the o-entleman suffered no more from his urethral trouble, 



* " Genito-Urinary Diseases with Syphilis." Van Buren and Keyes. 
Appleton & Co., N., Y. 1S74. 



274 GONORRHOEA AND ITS SEQUELS. 

To me, the case seemed to be one that pointed clearly 
to the leucorrhceal discharge, dependent upon the con- 
dition of the uterus, as the cause of the urethral discharge 
in the husband. This, and the case which I related at 
the last lecture, in which the patient produced a ure- 
thritis by the violent introduction of a sound, I would 
put forward as among those, where there is every reason 
to believe the urethritis to have been produced, by other 
causes than contact with a gonorrhceal discharge. 

Mr. Milton admits that " urethral discharges do appear 
in men as the result of connection with women laboring 
under leucorrhcea, in whom there is no reason to suspect a 
present or a previous blenorrliagia." This admission, 
however, is wholly negatived by the sentence which 
follows it, thus : " It must, I think, be equally admitted 
that the facts supposed to establish this, are, when we 
come to sift the matter closely, generally vague and 
few." The property of contagion, with Mr. Milton, 
points directly to specific cause ; to already existing 
gonorrhoea as the origin of it, in all cases, and where 
there is absolutely no evidence of such origin, and no 
reason to suspect it, belief to the contrary, Mr. Milton 
says, " must remain a mere conviction, and cannot be 
raised to the stability of truth." 

Mr. M. states, that in no case that he has read of, " is 
there anything to show that the surgeon had satisfied 
himself as to the previous state of the organs in both per- 
sons." On the strength of this, he would seem to claim 
that all the evidence in favor of the non-specific character 
of gonorrhoea, the carefully observed and reported 
cases of accepted authorities, are without value. Not- 
withstanding the positive belief acquired through the 
long and studious experience of such men as Ricord, 
Diday, Bumstead, Van Buren; and, unequivocally stated, 
we must believe all urethral discharges associated with 
the contagious element to have a gonorrhceal origin, 
" even when there is no evidence of such origin, and no 
reason to suspect it." Personal statements, from no 
matter whom ; circumstantial evidence ; character of 
individuals ; repeated coincidences ; all go for nothing. 

Even the case previously cited, when the disease was 



GONORRHCEA AND ITS SEQUEL/E. 275 

proven to be of traumatic origin, and which was proven 
to be contagious (and hence gonorrhceal) by the sup- 
posed proven communication to a presumably healthy 
wife, even this case may be waived out of the contest as 
among the not absolutely proven cases. 

We, however, must admit that all clinical observations, 
and investigations, are of necessity more or less empiri- 
cal, until carried to a point coincident with, or to the es- 
tablishment of some fixed physiological or pathological 
law. Until such is established, the most important, the 
most conscientious, and extensive, clinical labors must 
be open to the denial and depreciation of every passing 
observer, of little Or much experience. Thus it happens, 
that the most important question, upon the correct or 
faulty solution of which, the honor and happiness of 
individuals — even of whole families — may depend, the 
accumulated experience and the deliberate conclusions 
of our wisest men, are disregarded, and the specific na- 
ture of gonorrhoea asserted, upon the basis of a purely 
negative personal experience. If anything could give 
an incentive an dimpetus to a movement towards a more 
scientific solution of the matter, we certainly have it 
here. Naturally, we look to the great authorities in 
histological and pathological science, for some clue 
which shall lead to a more definite understanding of 
the true nature of the contagious element of gonor- 
rhoea, as well as that equally contagious property which 
is characteristic of conjunctivitis and infantile leucor- 
rhoea. 

Dr. Salisbury and others have, for many years, claim- 
ed a vegetable spore as the cause of gonorrhoea, but the 
persistent denial of this claim, by distinguished micro- 
scopists, at home and abroad, appears to have settled 
this question in the negative. But in a recent series of 
lectures on the relations of micro-organisms to disease, 
delivered before the Alumni Association of the College 
of Physicians and Surgeons, N. Y., by Dr. Belfield of 
Chicago, attention is again called to the alleged parisitic 
origin of gonorrhoea. In the opening of his third lecture 
Dr. B., alluding to the possible origin of gonorrhoea, 
says : " In 1879 Neisser made the assertion, based upon 



276 GONORRHOEA AND ITS SEQUELAE. 

numerous examinations, that there is present in the 
purulent discharge of gonorrhoea, whether from urethra, 
vagina, or conjunctiva, a micrococcus not found in other 
pus, distinguished by its size, shape, and mode of repro- 
duction. Neisser's previous work entitled this assertion 
to respectful consideration, and it was at once subjected 
to extensive tests. The reports have been, with one ex- 
ception, unanimous in corroborating Neisser's assertion 
in all its details. I may mention especially Ehrlich, a 
most expert and experienced, yet conservative and trust- 
worthy observer; Gaffky, a pupil and present assistant 
of Koch ; Aufrecht, of Madgeburg ; Loffler, Leistikow, 
Bockhart, Krause ; and among the ophthalmologists, 
Leber, Sattler, and Hirschberg. The only dissenter, so 
far as I know, is Dr. Sternberg, who asserts that this 
micrococcus form is widely distributed, and is, in fact, 
the same as that which Pasteur has shown to cause fer- 
mentation of urea. 

Several attempts have been made to inoculate human 
subjects — since animals are not susceptible to the con- 
tagion — with the isolated micrococci. Bokai, in Pesth, 
asserts the induction of urethral gonorrhoea, in three out 
of six students so inoculated ; but as he neglected to 
keep them in solitary confinement during the trial, the 
experiment is not so convincing as it might be. Bock- 
hart, having cultivated the organisms on gelatine, in- 
oculated with the fourth culture a paralytic hospital 
patient, and observed a typical gonorrhoea on the sixth 
day. Sternberg cultivated micrococci from gonorrhceal 
pus in flasks, and observed only negative results in each 
of five patients inoculated therewith. Thus far, there- 
fore, it is not decisively established that the bacte- 
rium associated with gonorrhoea is the cause of the 
disease. 

Sattler has recently found micrococci, apparently 
identical with those of gonorrhoea, in the conjunctival 
granulations, and affirms that inoculation with the organ- 
isms, isolated by cultivation, induced the disease in a 
human subject. 

Micrococci, then, exist in the human body, locally 
and generally ; yet excepting gonorrhoea there is no 



GONORRHOEA AND ITS SEQUELS. 277 

decisive evidence that a specific micrococcus is associ- 
ated, exclusively, with any one specific morbid process 
in the human subject." 

It will be remembered that in 1872, Lostorfer, of 
Vienna, claimed to have discovered a corpuscle or 
baccillus, which was peculiar to syphilitic disease, and 
this discovery was announced and proven to the entire 
satisfaction of Skoda, Hebra, and Strieker, and was 
disputed by Wedl, Gruber, and Neuman. Professor 
Strieker, however, at once commenced a series of in- 
dependent operations for the purpose of ascertaining the 
validity and real significance of Lostorfer's discovery. 
The alleged corpuscle was found in syphilitic blood, 
but it was also found in the blood of persons not syphi- 
litic, but who were subjects of cachexia from other 
causes. 

In the more recent discovery of the gonorrhceal ba- 
cillus not only has it been asserted present in every 
specimen of gonorrhceal pus, but typical gonorrhoea is 
claimed to have been set up, through its inoculation upon 
persons previously free from the disease. Through the 
kindness of Dr. Belfield I have been enabled to observe 
the microscopic appearances of the so-called gonorrhceal 
bacillus or micrococcus. About the diameter of a 
white blood-corpuscle, it is made up of fine, apparently 
round points, loosely arranged in a kidney-like form 
about the diameter of a white blood-corpuscle, and 
apparently occurring in about the same frequency, in 
comparison with the red. Other and more critical ex- 
periments will be required before the claim of its specific 
power can be admitted. In the cultivation of these 
bacilli for experimental purposes the difficulty of secur- 
ing absolute freedom from the fluid originally associated 
with them, and commonly accepted as capable of setting 
up a gonorrhoea, without the intervention of a bacillus 
of any sort, must be very considerable. 

The subjects of experiment must be secured against 
even the possibility of sexual contact. In the six cases 
cited, the chance cf acquiring a gonorrhoea in the interest 
of medical science, might be accepted as an opportunity 
to take the risks of ordinary contagion under cover of 



278 GONORRHOEA AND ITS SEQUELS. 

the scientific experiment. The fact that out of six 
inoculations, under apparently similar circumstances, 
three only were successful, is worthy of note. Stern- 
berg's claim that a micrococcus, identical in appearance 
with the so-called gonorrhceal micrococcus, is often 
found in fluids entirely independent of gonorrhceal in- 
fluence, would, if proven, at once relegate this discovery 
to the records of Lostorfer's corpuscle. The statement 
(oral) of Dr. Belfield that, in his experiments, such a 
micrococcus, has been repeatedly found in the pus of 
sores on the hands of students working much in the 
dissecting-room, is significant. If it does not wholly 
disprove that the origin of the alleged gonorrhceal 
micrococcus, it nevertheless shows that it is only one 
among the causes hitherto claimed as capable of initiat- 
ing the disease and hence loses much if not all of its 
practical value as a scientific discovery. 

It has occurred to me that the difficulty of settling 
the question with reference to the specific character of 
gonorrhoea, may be simplified, if we can go behind all 
clinical records, and consider the changes which occur 
in the transition between the normal formation of 
epithelial elements and the characteristic pathological 
products. Rindfleisch — and his opinion is entitled to 
consideration — in discussing the question of the for- 
mation of epithelium, uses a significant phrase, namely, 
"epithelial infection," and says: " The opinion is in- 
evitable that the embryonal formative cell, can only 
become an epithelial cell, when it comes in contact with 
such ; we must believe in a kind of epithelial infection!' 
That is to say, when a formative embryonal cell comes 
up from the cellular tissue to take the place of a cell 
that has preceded it, its form and character is deter- 
mined by coming in contact with epithelial cells already 
formed. 

With reference to other tissues, it is claimed that the 
peculiar form which the germinal or formative cell is 
to take is determined by contact with the tissue of which 
it is destined to become a portion. 

If this view is accepted, we have infection as a 
physiological process, and then the interesting question 



GONORRHOEA AND ITS SEQUELS. 279 

arises, at what point does the epithelial element cease 
to have the infective influence ? In other words, at what 
point does it cease to have the contagious property? 
For, it is here distinctly shown, that normal epithelial 
elements, possess an essential and characteristic property 
of contagion. If this be the case, shall we accept the 
contagious element as evidence of gonorrhoea, when we 
find it in the physiological process? As soon as the 
fact, that a contagious principle is contained in the 
physiological constitution of the parts, is recognized 
the doctrine of contagion receives a fatal blow. One 
thing is very certain, viz., that as long as the physiolo- 
gical infection, this influence of epithelial cells by their 
contact with each other, is continued in a salutary way, 
it gives rise to no disturbance whatever, and the 
thought of contagion does not arise. But when a cell, 
which has fallen from its integrity, exerts its vicious in- 
fluence upon other cells, disturbance is manifest, and 
compels attention to its character and powers. 

Because gonorrhceal disease is contagious, it has 
been claimed that this property must be regarded as 
evidence of the presence of a special virus. If, how- 
ever, it is the contagious property alone that is charac- 
teristic, and this property is the proven attribute of all 
epithelial cells, it can no longer be regarded as evi- 
dence of the specific character of gonorrhoea ; hence 
the only distinction to be recognized, between gonorrhoea 
and urethritis, is a moral one. The term gonorrhoea 
implies gross immorality. A good man, then, with 
simple urethritis, perhaps occurring independent of 
sexual contact, may, by injudicious living or venereal 
excess, elevate his simple urethritis up to a contagious 
point. Then he has gonorrhoea. He has done nothing 
morally wrong ; he has simply been placed without the 
pale, because of his urethral discharge assuming a con- 
tagious form. In that condition, he has, perhaps, com- 
municated the disease to his wife, who would, under 
Mr. Milton's teachings, be qualified to sue for a divorce, 
and to obtain it, notwithstanding there was no evidence 
of gonorrhceal origin, nor any reason to suspect it. 



280 GONORRHCEA AND ITS SEQUELS. 

DIFFERENTIAL DIAGNOSIS. 

Having endeavored to ascertain what gonorrhoea is, 
we will briefly allude to the question of differential diag- 
nosis. 

Inflammation of the mucous membrane covering the 
glans penis and reflected upon the prepuce, termed balani- 
tis, may be mistaken for gonorrhoea. This condition 
may arise from various causes, such as irritation pro- 
duced by accumulation of sebaceous material beneath 
the prepuce, or from hypertrophy of the papillae of the 
mucous membrane covering of the glans, as in the case 
exhibited this afternoon. 

In that case, the irritation produced by the enlarged 
papillae, had given rise to pus, which had accumulated 
beneath a long prepuce, in such quantity, that, when 
the prepuce was pressed, a discharge from the preputial 
opening took place, that could very readily have been 
mistaken for one issuing from the urethra. 

I have encountered cases in which such a mistake has 
been made, and injections containing various astringent 
and irritating materials used for months under the sup- 
position that the patient was suffering from gonorrhoea, 
when in truth the urethra was free from all disease ex- 
cept that produced by the injections. In some of these 
cases, because of the degree of phimosis present, it is 
difficult to ascertain whether the discharge issues from 
the urethra or not ; but your treatment should not be 
commenced until that question has been settled. 

The next point is to ascertain, whether the disease you 
are called upon to treat, is a simple urethritis or a gon- 
orrhoea acquired by contagion. 

In most cases, the character of the exposure is not 
well understood, either by the person exposed or by the 
physician. When a discharge appears in the urethra of 
the male, after illicit intercourse, the presumption is in 
favor of a gonorrhoea, existing in the woman with whom 
such intercourse is held. At the same time, this is not 
certain, for we know that other causes are capable of 
originating a discharge, to all appearance identical with 
it. 






GONORRHOEA AND ITS SEQUELS. 28 1 

Quite commonly, (not so much now as formerly, how- 
ever) an attempt is made to cut the disease short by the 
use of some active injection. This plan is fast going 
into disrepute, and justly so, for by adopting it, the 
advantage is at once lost, of being able to determine 
whether the disease would not have readily passed 
away, within a few days by the use of simple means. 
By such treatment you necessarily add an inflammatory 
trouble, and if the case is one of real gonorrhoea, you 
will increase the activity and the inflammatory charac- 
ter of the disease. 

I have met with a large number of urethral strictures, 
several thousands, and I have made it a point to look 
up their origin, and to learn concerning the disease which 
gave rise to them, how the previous gonorrhoeas were ac- 
quired, and how treated. I have not yet found a single 
case, which recovered within four weeks, where the 
symptoms were such as to convince me that the patient 
suffered from a gonorrhoea that had been acquired from 
a gonorrhoea. In every instance in which the evidence 
was positive upon this point, the gonorrhoea had lasted 
at least four weeks. There are many cases of gonor- 
rhoea in which the patient, on account of his youth or 
extreme modesty, neglects to seek professional advice, 
and yet these very ones pass through their trouble in 
about the same time as those who avail themselves of 
eminent professional service. The same is also true of 
many cases reported to me treated by homeopathic 
remedies, and through the German method, by baths 
alone. I do not give much credit to the plans which 
have been brought forward for shortening the duration 
of the disease, be the treatment what it may. Treat- 
ment may aggravate the case, and it may also make the 
patient much more comfortable than if the disease is left 
to pursue an unmodified course. The urine can be made 
less acrid by a variety of means ; the distressing symp- 
toms, such as chordee, etc., may be relieved ; but as to 
cutting the disease short, I do not believe that it can be 
done. 



282 GONORRHCEA AND ITS SEQUELS. 



LESSON XXXIII. 

ON THE TREATMENT OF GONORRHCEA. 

Distinction between gonorrhoea and urethritis — Necessity of ascertain- 
ing antecedent facts in regard to the causes of the disease — Usual 
method of treating cases of supposed gonorrhoea — Probable duration 
of the disease — True gonorrhoea never lasting less than four weeks — 
Various causes which give rise to a urethral discharge which may be 
mistaken for a gonorrhoea — Cases in illustration — Lithiasis a cause — 
Illustrative case — Urethral discharge simulating a gonorrhoea pro- 
duced by contraction of the urethral orifice — Cases in illustration. 

In the preceding lesson it has been shown that there 
are no rules, clinical or scientific, by which we can 
solve the difficult and constantly recurring problem, of 
the causes which have produced a purulent contagious 
urethral discharge, in cases of doubt, and this simply 
from the fact, that the disease is not of specific origin, 
but may be produced in various ways. It is equally 
apparent, that the disease varies in its intensity, and in 
its amenability to treatment, and yet this does not 
prove that its cause was from a gonorrhceal source, or 
from a variety of other causes. It is suggested by Van 
Buren and Keyes (p. 53 of their work,) that only those 
cases " derived unmistakably from an individual of the 
other sex with a gonorrhoea," should be called gonorrhoea, 
and that in cases having other origin, and for cases of 
doubt, the term urethritis should be employed. This 
appears to me an excellent distinction to make, not 
only to keep in mind the possibilities of a purulent ure- 
thral inflammation, free from any moral obliquity, but 
to lead to intelligent treatment of the presenting dis- 
ease. 

The important preliminary, then, to the treatment of 
such urethral discharges, is to ascertain all the ante- 
cedent facts bearing upon the history and development 
of the difficulty. It used to be a very common fashion, 
when a patient called upon a surgeon complaining of 
trouble supposed to be gonorrhceal, to write a hasty 



GONORRHCEA AND ITS SEQUELS. 283 

prescription, calling for a copaiba mixture, a syringe, 
and an injection, more or less astringent or irritant. 
Then, after directing the patient to drink plenty of flax- 
seed tea, and to omit indigestible food, alcoholic and 
fermented drinks, the case was for the time dismissed. 
Or else, if the person affected was very urgent to be 
cured at once, especially if it was a married man, tem- 
porarily enjoying the privileges of a city life, to pre- 
scribe promptly, or to administer, a strong caustic in- 
jection, with the expectation, at least with the hope, of 
aborting the disease. 

All the text-books treating of this matter have been, 
for the last fifty years, in great harmony in regard to 
the use of copaiba and injections in. great variety for 
such cases. One of the latest and most valued author- 
ities on other venereal diseases has presented ten co- 
paiba prescriptions and seventeen formulae for injec- 
tions, to be used in the discretion of the practitioner 
during the acute stage of gonorrhoea, and this is a fair 
sample of the usual teaching on this subject. 

In the matter of internal treatment, demulcents, alka- 
lies, diuretics are prescribed as palliative, but the agent 
upon which all seem to depend for a cure is the balsam 
copabia in some form. 

For local treatment injections of nitrate of silver of a 
strength of 5 to 20 grains to the ounce of water, are 
used in the attempt to abort the disease. For the acute 
stage various salts of zinc, copper, lead, iron, etc., are 
in use for alterative or astringent effect. 

A running fire, commenced at the first tickling sensa- 
tion in the penis after a suspicious connection, is kept 
up with injections, more or less irritant, and medicines, 
not only disgusting to both smell and taste, but which 
interfere with digestion, and often cause important gas- 
trie troubles. 

And with all these aids a distinguished recent au? 
thority, in summing up the results of treatment by the 
methods and remedies above alluded to, says : 

" The reader may be interested to know, what is the 
average duration of treatment required, in the hands of 
the best surgeons, for the cure of gonorrhoea, laying 



284 GONORRHCEA AND ITS SEQUELAE. 

aside those cases seen in the first stage, and which are 
speedily cured by the abortive method. This may be 
estimated at four to six weeks. Greater success on the 
average is not probably attainable by a?iy means with which 
we are at present acquainted."* 

Again, on page 52, it is stated, in regard to those 
cases, said above to be speedily cured by the abortive 
method: " Taking the usual run of cases met with in 
practice, not more than one out of twenty is seen at a 
sufficiently early period to admit of the abortive treat- 
ment." 

If, then, we can accept an average recovery of four 
to six weeks as a satisfactory result of the most judi- 
cious use of specific remedies and injections in variety, 
a method of treatment which claims, at least, equally 
good results, without specifics and without injections, 
is certainly worthy of your consideration. 

Now in order to examine this claim fairly we may 
profitably refer to the statement made in the commence- 
ment of this lesson, viz., " The important preliminary 
in the treatment of acute urethral discharges is to as- 
certain all the antecedent facts bearing upon the his- 
tory and development of the difficulty." 

A patient presenting with a history of slight urethral 
sensitiveness, following from one to ten days after a 
suspicious venereal contact, and this supplemented 
within a few hours or days by a slight mucous or muco- 
purulent discharge, suggests the desirability, when 
possible, of examining the female with whom connec- 
tion was had ; next, to ascertain the previous condition 
of the urethra affected ; next, the circumstances of 
greater or less sexual indulgence or excitement, char- 
acter of diet, kind and amount of beverages used, etc. 

Such a condition of urethral irritation may be the 
result of contact with a leucorrhcea, more or less ir- 
ritant, or with the menstrual fluid immediately before, 
during, or after the period. Or it may be the result of 
inflammatory action set up behind a urethral stricture. 
Or, in a urethra long irritated by passage of gravelly 

* Bumstead and Taylor, 1879, page 76. 



GONORRHOEA AND ITS SEQUELS. 285 

urine, simply by unusual venereal excitement. If to 
this the influence of alcoholic or fermented liquors is 
added, the appearance of such a discharge would not 
be remarkable. Mr. Reginald Harrison, of Liverpool, 
reports the case of a medical practitioner who suffered 
from a puriform discharge, heat and pain along the 
course of the urethra, attended with frequent micturi- 
tion, chordee, and sympathetic fever, after eating 
largely of asparagus. (In this case the urethra was 
probably not in a previously healthy condition.) 

Irritation in the rectum, as by ascarides, may pro- 
duce it. A syphilitic neoplasm, initial lesion, or sec- 
ondary papule, just within the urethra and scarcely 
abraded, may do it. 

Finally, it may be the legitimate result of contact 
with a gonorrhceal secretion in a female suffering with 
that disease. 

The following cases are presented to illustrate the 
various possible causes of a urethral discharge, inde- 
pendent of contagion : 

B. N., physician, 40 years of age, spending a few 
weeks in the city, in order to avail himself of the col- 
lege teachings, was about to return home, when he sud- 
denly became aware of a slight twinge at the urethral 
orifice on urination. Although trying very hard to 
ignore the matter, he could not help realizing the fact 
that the trouble was increasing, and, after a sleepless 
night, on the morning following he examined his penis. 
He found the orifice quite red, and easily pressed out a 
drop of pus. He came early to my office, announced 
his trouble in a manner which indicated great mental 
distress, confessed to an impure sexual connecticn three 
days previous to the first abnormal sensation in his pe- 
nis, and stated further, that he was a married man, 
whose wife would certainly come after him if he did 
not arrive at home within a week from that date. 
Under these circumstances, he begged that the abortive 
treatment might be at once and thoroughly resorted to 
in his case. Examination confirmed the doctor's state- 
ment in every particular, and he again plead with great 
earnestness that a strong nitrate of silver injection 



286 GONORRHOEA AND ITS SEQUELS. 

might be used at once, and offered repeatedly to take 
entire responsibility as to consequences. He had re- 
peatedly treated patients by the abortive method, (for- 
tunately for him, however, without success,) but en- 
couraged by assurances of possible immediate cure, 
he begged for the chance, especially as it was scarcely 
twenty-four hours since the first urethral symptom oc- 
curred. He was quieted with great difficulty. I ex- 
plained to him very fully my positive convictions as to 
the nature of urethral discharges which were apparent- 
ly cured by the abortive treatment. In his case there 
was a history of an attack of gonorrhoea nearly 20 years 
previous, and no sign of trouble afterwards. 

He went at once, by my advice, to see the woman 
with whom he had had connection. She was an inmate 
of a house of prostitution, and claimed that she had no 
disease, but refused to be examined. Encouraged, how- 
ever, by the girl's statement, he consented to go at once 
to bed, and treat himself exactly as I had advised, 
which was to avoid all specifics and injections, and to 
rely upon local antiphlogistic measures, with alkalies 
and diuretics internally. 

The result was that on the fifth day thereafter he 
came back perfectly free from any evidence of disease. 
He quite agreed with me that the attack might be due to 
some simple leucorrhceal or menstrual secretion, or was 
probably from a stricture due to his early gonorrhoea. 
As he intended leaving for his home at once, it was de- 
cided not to examine his urethra for stricture, and he 
left rejoicing at his narrow escape from a personal ex- 
perience in the abortive method. 

Again, not long since, a medical gentleman from a 
neighboring city brought an important patient for an 
opinion as to a discharge which, coming on after a sus- 
picious contact, had persisted, more or less acutely, for 
over four months. His history was as follows : 

He had never had any previous gonorrhoea. He had 
been married for ten years ; had never during this time 
noticed any urethral discharge. He had had a single 
illicit connection, and was in great fear lest he had ac- 
quired some venereal disease. Through frequent ex- 



GONORRHOEA AND ITS SEQUELAE. 287 

aminations and squeezing the penis to detect, as early as 
possible, any commencing discharge, he finally, on the 
morning of the fifth day, succeeded in pressing out a 
small drop of fluid which appeared to be purulent. He 
at once called on his physician, and begged him at all 
risks to make some application which would cut short the 
disease. There was no unusual sensitiveness in the ur- 
ethra, very slightly increased redness at the orifice, which 
was said to have been florid habitually. The doctor was 
quitec ertain that there was no true gonorrhoea present, 
but that it was a slight urethritis caused by simple leucor- 
rhcea, or similar irritant, and advised Vichy water. The 
patient, however, would not be pacified, until he had 
given him an injection to use. This was composed of 
acetate of zinc and acetate of lead, each four grains, to 
four ounces of rose-water, to be used three times a day. 
Under the influence of this injection, the discharge 
promptly increased accompanied by some pain on 
urination, and continued in spite of demulcents, alkalies, 
and diuretics, for several weeks, without improvement. 
The injection was changed repeatedly, ringing the 
changes on the salts of zinc, lead, and copper, in solu- 
tion and in soluble bougies, and adding sandal oil cap- 
sules, and finally the Lafayette mixture,* cubebs, etc. 
This course was said to have been faithfully pursued 
for over four months. In this time there were several 
periods, of a few days each, during which the discharge 
appeared almost to have ceased, but the improvement 
was only temporary, the discharge soon returning to 
former profuse character. This was the condition of 
things when the doctor called with his patient at my 
office. On examination, the case appeared like that of 
a genuine gonorrhoea in the declining stage. Meatus, 
which was large (30 F.), was quite red, the urethra very 

* Lafayette mixture, a standard remedy in general use for gonorrhoeal 
troubles, composed of : 

Copaiba ^ i 

Liq. Potassa 3 ii 

Ext. Glycyrh § ss 

Spts. aeth. nit 3 i 

Syrp. Acac ? vj 

M. 



288 GONORRHCEA AND ITS SEQUELS. 

tender to the passage of the urethrometer. This, in a 
penis of three and a half inches circumference, was 
readily turned up to thirty-four at the bulbo-membran- 
ous junction, and while by slight traction it moved for- 
ward easily, considerable tenderness was complained 
of. At thirty-two, it caused only a feeling of slight 
uneasiness, and came smoothly through and with a 
little stretching out of the urethra at this size, but fol- 
lowed by quite a little oozing of blood. This pretty 
certainly eliminated stricture, as a cause for the con- 
tinuance of the supposed gonorrhoea, and showed an 
engorged and villous condition of the whole mucous 
membrane. On careful enquiry as to exactly what the 
patient was doing, and how he was living during the 
short periods of improvement which had been noted, 
it appeared, when critically recalled, that each one had 
corresponded with absence from home, and under cir- 
cumstances where he was unable to pursue his treatment 
with that thoroughness which was his habit at home. 
Having seen quite a number of similar cases where a 
chronic lithiasis had produced urethral conditions which, 
aggravated by treatment for supposed gonorrhoea, pre- 
cisely resembled those in the above case, this was sug- 
gested as a probable explanation. The doctor at once 
confirmed my suggestions by the statement that for more 
than three years previous to occurrence of the supposed gonor- 
rhoea he had been treating the patient for lithiasis, brick-dust 
deposits in the urine having been present much of the 
time. An immediate examination of the urine showed it 
to be highly acid, and freshly voided, under the micro- 
scope, showed occasional crystals of uric acid. (A few 
hours after, the characteristic, red pepper-like grains 
were deposited). It was suggested that this lithiasis 
was directly and solely responsible for the origin of the 
supposed gonorrhoea. It is not at all uncommon in such 
cases by persistent stripping the penis, in the effort to 
discover a discharge, to bring forward a little muco- 
purulent discharge, especially in cases where there is 
urethral contraction even very slight. The contraction 
at the orifice in this case, only four millimetres, might 
readily have caused a slight collection of secretion from 



GONORRHCEA AND ITS SEQUELS. 289 

the habitually irritated mucous membrane, sufficient to 
account for what was seen in the first instance, and 
upon the strength of which, alone, the treatment of 
gonorrhoea was initiated. 

In accordance with my advice, all treatment by in- 
jection was stopped, also specific medicines, which had 
greatly disturbed his digestion. His mind was relieved 
by the assuranse that his trouble was not, and never 
had been, gonorrhceal. He was put upon a course of 
blue pill and iron, with dilute nitro-muriatic acid, and 
advised to keep his skin in order by morning exercise 
and sponge bath, followed by brisk frictions, preferably 
with hair gloves. The result was not ascertained for 
several months, but it finally proved to be in full accord 
with the view which was taken of the case. The dis- 
charge speedily lessened, and without the slightest treat- 
ment locally, or otherwise, ceased entirely in the course 
of three or four weeks. But for the anxiety consequent 
upon an illicit connection the discharge, which had prob- 
ably been present in an equal quantity for months, would 
in my opinion never have been discovered. Several cases 
almost identical with the foregoing, warrant the inclu- 
sion of this view in any case of newly discovered ure- 
thral discharge. Again, there is a variety of purulent 
urethral discharge not very rare, which is apparently 
independent of any contagion, or sexual excitement, 
and which is usually confined to the immediate vicinity 
of the urethral orifice. I have never seen it except in 
connection with a decided contraction of the canal at 
this point, congenital or acquired. It is usually quite 
painless, although I have in a number of instances seen 
it completely simulating a mild form of gonorrhoea. 

Thus, a gentleman brought his son, a lad of sixteen, 
to enquire as to the nature and importance of. a slight 
purulent discharge, of which complaint had been made 
for two or three days. The boy had acquainted his 
father with the fact on its first appearance, and denied 
all knowledge of its origin ; he had accidently noticed it 
one morning on rising. There was not the least exter- 
nal evidence of inflammation or irritation. A drop of 
creamy pus evidently collected behind a quite narrow 
(20 F.) meatus, was by slight pressure easily made to 



29O GONORRHCEA AND ITS SEQUELS. 

exude. I have habitually attributed such discharges 
to accumulation of irritating crystalline material de- 
posited during the passage of the urine, and aggravated 
by the necessary friction during the passage of urine. 
The urine in this case proved to be highly acid, and 
contained uric acid crystals, and under treatment for 
this, the discharge passed off, and now, for four years, 
has not returned. 

Two brothers, twins, fifteen years of age, were sent 
to me, the one complaining of a constant sense of irrita- 
tion at the urethral orifice, causing him much annoyance 
and which he had experienced more or less for a year, 
and there was slight redness and pouting of the lips of 
the meatus, but not the least trace of any discharge. 

His brother had a slight purulent discharge, which 
he stated was first seen six months previously. He 
stated also that he had been accused of having acquired 
it by sexual contact. This he stoutly denied. The 
brothers were inseparable and his twin confirmed the 
denial. He had been treated by injections and internal 
remedies, including copoiba, with alkalies, etc., but with- 
out avail. The amount of discharge was perhaps equal 
to three or four drops a day, and ten at night. Both 
were annoyed by too frequent desire to urinate, once in 
three or four hours, but not at night. The urine in both 
was apparently normal in quality and quantity. The 
urethral orifice in both boys was 21 F., while the nor- 
mal calibre in each was 32 F., the penis in each case 
being 3J inches in circumference. I divided the orifice 
at the same time in both cases to 32 F. No other treat- 
ment was resorted to. The first mentioned was relieved 
of his irritation, immediately on the division of the con- 
traction, and it did not return. The second was quite 
well of his discharge in about two weeks, or about one 
week after complete healing had taken place. 

The foregoing cases, cited for the purpose of illus- 
trating the occurrence of irritation and purulent ure- 
thral discharge, independently of any contagion, and 
also of the quality of the urine, have not been of rare 
occurrence in my experience, my attention having been 
quite frequently called to such cases during the previous 
fifteen years. 



GONORRHOEA AND ITS SEQUELS. 291 



LESSON XXXIV. 

Acquirement of urethral discharge simulating gonorrhoea through mediate 
contagion — Cases in illustration — Urethral stricture the most common 
of all the causes of purulent urethral discharge — So-called latent gonor- 
rhoea — Claims for such a source of contagious urethral discharge not 
well founded — The real explanation referred to irritation caused by irrita- 
tion from urethral stricture — Explanation of the mode in which purulent 
secretions due to stricture occur — Statistics in regard to the cure of gonor- 
rhoea by the abortive methods untrustworthy — A very large proportion 
of discharges not of true gonorrhoeal origin, the tendency of which is to 
get well without specific treatment — Views and practice of authorities — 
No reliable evidence of success by the abortive methods — Average 
duration of true gonorrhoea not less than four weeks. 

Another source of urethral inflammation and purulent 
discharge is through mediate contagion. From the fact 
that this origin of a purulent discharge, if not denied, is 
usually ignored, I wish to state explicitly my conviction 
that gonorrhoea is occasionally contracted in this way. 
The fact that such acknowledgment may be made use 
of to account for gonorrhoea, legitimately acquired, is no 
reason why the dangers and possibilities of contagion, 
through the medium of public privies and urinals, 
should be denied or undervalued. Theoretically, a drop 
of gonorrhoeal pus from male or female, might easily be 
deposited on the seat of a privy in the locality where 
the urethral orifice of the next comer would, without 
especial care was used to prevent, come in contact with 
such pus ; and this, as certainly and as effectively, for 
purposes of contagion, as if the contact had been through 
sexual connection with the person in whom the pus had 
originated. 

Practically, men almost everywhere are habitually 
careful that such contact is prevented, and hence such 
cases are infrequent ; but to prove that the danger is 
real the following cases are presented : 

M. P., a graduate of the College of Physicians and 
Surgeons, N. Y., of ten years' standing, was settled 
in a large town in New Jersey. Some three years since 
I received a letter from him stating his remembrance 



292 GONORRHOEA AND ITS SEQUELS. 

of my teaching in regard to the possibilities of acquiring 
gonorrhoea through mediate contagion, and also of his 
incredulity then on that point ; still farther, that he had 
recently been convinced that true gonorrhoea could be 
acquired in that manner, through a painful personal ex- 
perience. He then stated that he had, when a student, 
a typical gonorrhoea, and was perfectly familiar with 
all its characteristic features. That there was no reason 
for bringing his case to my attention, except in support 
of a scientific fact which had been disputed. He then 
stated, that about three weeks previously, he had occa- 
sion to spend the day in a neighboring city. Having 
the necessity to use, in some haste, the privy of the hotel 
where he stopped, he neglected the usual precautions. 
On the fourth day thereafter, he became aware of an 
uneasy sensation at his urethral orifice, and, on exami- 
nation, found it quite florid and moist ; slight pain on 
urination followed, and by the next morning a distinct 
purulent discharge was found to be present. This, un- 
der internal treatment by alkalies, demulcents and diu- 
retics, without injections, had progressed, increasing in 
activity, for about a week, characterized by painful uri- 
nation, chordee, and free greenish purulent discharge. 
The disease then began to diminish in intensity, and at 
the time of writing was in the third week, with discharge 
still profuse, but comparatively free from pain, except 
from some remaining chordee, which continued to give 
him some annoyance at night. He further stated, that 
he had had neither connection or any sexual contact or 
excitement, for more than a month prior to the appear- 
ance of the gonorrhoea. He expressed a willingness to 
come to New York and give me the opportunity of 
personal examination of his case if, in the interest of 
science, it was thought desirable. In response to my 
affirmative reply, he came a day or two after, and his 
condition, one of sub-acute purulent urethritis, was read- 
ily appreciated, and a thorough analysis of all the alleged 
facts in the case, resulted in my complete acceptance of 
it as one of gonorrhoea, acquired through mediate con- 
tagion. During the summer following the foregoing oc- 
currence a medical man sojourned temporarily at a sea- 



GONORRHCEA AND ITS SEQUELS. 293 

side hotel where the privy accommodations were inade- 
quate, and difficulty was experienced in preventing un- 
pleasant contact with the seat. This was so positive an 
annoyance that, through representation to the propri- 
etor of the discomfort and danger of infection, from 
such conditions, the difficulty was promptly remedied. 
Within a day or two after, the complainant began to 
experience discomfort at the urethral orifice, and a slight 
white purulent discharge appeared, quite independent 
of any venereal contact or of any known cause, except 
the privy aforesaid. This mild urethritis was treated 
only by injections of a two-grain solution of alum by 
means of a recurrent syringe. It did not increase or 
diminish for a week. The chief annoyance was from 
painful erections at night without chordee. The dis- 
charge then gradually declined, and at the end of the 
second week was no longer visible. The congested and 
swollen appearance of the orifice was noticeable for 
still another week, and it was some days after this, or 
over three weeks after the commencement of the trouble, 
before the erections ceased to cause annoyance. This 
case, at the time of its occurrence (summer of 1880), 
was confidentially communicated, as of scientific im- 
portance, to Dr. L. B. Bangs, by the sufferer, whose 
position as a clinical teacher in the department of genito- 
urinary diseases might be supposed to give especial 
value to his opinion, viz., that the disease in his case was 
not of gonorrhceal origin, and unequivocally acquired 
through mediate contagion. 

But the most common of all the causes which initiate 
a purulent urethral discharge, which may be mistaken 
for a gonorrhoea acquired by contagion, is urethral 
stricture, and this, too, often but slightly infringing upon 
the normal calibre of the canal. However difficult we 
may find it to explain the exact manner in which the 
result is brought about, the capacity of a urethral stric- 
ture to set up a contagious purulent discharge in a 
urethra otherwise normal, and this, too, independently 
of any contact with contagious material of any sort, is 
in this day beyond the chance of any serious question. 
It is true that in accounting for this we may accept the 



294 GONORRHCEA AND ITS SEQUELS. 

view implied in explanation of the so-called " latent 
gonorrhoea" of Noeggerath. This claims that, once a 
man has acquired a gonorrhoea from contagion, he 
never gets quite rid of the contagious property which 
has been engrafted on his urethral mucous membrane. 
On the contrary, after a period of years, during which 
there is no tangible evidence of the disease, the dis- 
charge, practically identical with the original gonor- 
rhoea, mysteriously returns with all its original capacity 
for infecting healthy mucous membranes. This theory 
has been advanced to account for the fact that many 
women, who before marriage were perfectly free from 
uterine and ovarian disease, after marriage become af- 
fected with such disease, and in a way which warrants 
the conclusion that it had its origin in a contagious 
element derived from a husband previously affected 
with gonorrhoea, and this notwithstanding an apparent 
freedom from any sign of the disease for years. The 
fact that disease is often so communicated is undeni- 
able, but the explanation of it is much simpler and 
more in accordance with known pathological conditions 
and processes, and without admitting a mysterious la- 
tency for gonorrhoea. The non-specific origin of gon- 
orrhoea as claimed and explained in a previous lesson, 
makes it not only possible, but probable, that the me- 
chanical irritation caused by a urethral stricture may 
produce a purulent discharge ; and this whether the 
stricture, under circumstances of similar aggravation, 
is of simple — that is to say, of gonorrhceal, diathetic — 
or of traumatic origin. And that this discharge, what- 
ever its origin, simply from the fact that it is puru- 
lent, may, through known influences, such as low con- 
dition, acrid natural secretions, excess in living, sexual 
indulgence, etc., acquire a contagious property. It 
will then be seen that a stricture may develop at any 
period after an acute attack of gonorrhoea, even after 
a long period after the absolute cure of the original 
inflammation, and that as the simple mechanical in- 
fluence of a stricture may produce a purulent discharge, 
any purulent discharge may be elevated by certain 
favoring conditions into a highly contagious character. 



GONORRHOEA AND ITS SEQUELS. 295 

The explanation of a contagious discharge, occurring 
years after a gonorrhceal inflammation has passed 
away, is in complete accord with known and accepted 
pathological conditions and processes. It will also be 
seen by the foregoing statements of fact, that purulent 
discharges of more or less contagious character coming 
on after sexual intercourse are not of necessity gonor- 
rhceal, but may, and — from the fact that a large propor- 
tion of the cases where a suspicious discharge appears 
have, at some previous, time suffered with gonorrhoea — 
are quite likely to find the cause of such discharge a 
stricture of the urethra more or less salient. 

From the fact that always behind a stricture there is 
a congested condition of the mucous membrane, ready, 
on slight additional provocation to produce a catarrhal 
discharge, and from the fact that sexual excitement is, 
above all other influences, most likely to furnish that 
provocation, it will be easily seen that the appearance 
of a purulent secretion, after sexual contact, is not of 
necessity the result of a new contagion, and that the 
treatment of such discharge, by means addressed to the 
abortion of a gonorrhoea, would probably aggravate the 
existing trouble, that the cessation of such discharge 
after such treatment, would not prove that a gonorrhoea 
had been aborted. Therefore, it may be claimed that 
the wisest course, in all cases of doubt, will be to with- 
hold all measures tending to obscure the diagnosis, es- 
pecially such as the use of caustic injections, which have 
never yet been absolutely well proven to have cured a 
single case of gonorrhoea. 

The statement has already been quoted from accepted 
authority that, " laying aside those cases which are speed- 
ily cured by the abortive method," the remaining 
cases of gonorrhoea run an average period of not less 
than four to six weeks, and that not more than one case 
in twenty is seen sufficiently early to warrant hope of 
success by the abortive method. It may be confidently 
stated, that it is impossible to distinguish such a case 
from one where the inflammation is induced by any one 
of the various causes previously mentioned, until the 
disease, if of gonorrhoea! origin, is too far advanced to 



296 GONORRHCEA AND ITS SEQUELS. 

warrant any hope of cure by the abortive method. Thus 
it is, that the statements and statistics presented from 
time to time, in regard to cure of gonorrhoea by the 
abortive method, are of necessity untrustworthy. I 
have used this method many times in past years, and 
some cases presenting symptoms which might have been 
due to gonorrhceal infection, were apparently cured in 
a few days. But I have uniformly failed in cases (and 
they were many), where 1 knew the source of the dis- 
charge to be a gonorrhoea, which had communicated to 
others a gonorrhoea. In consequence of these repeated 
failures, I abandoned the abortive method, fully fifteen 
years ago. Since that time, instead of attempting to 
abort a gonorrhoea, in every case in which a purulent 
discharge had appeared, with more or less smarting, 
from twenty-four hours to a week after a suspicious 
connection, I have waited further information as to the 
nature of the disease in each particular case. I have 
waited not only because of lack of faith in any abortive 
measures, but because I have believed and still believe 
that a very large proportion of urethral discharges are 
of simple origin, and will get well in a few days under 
the most ordinary hygienic measures, and because I do 
not, and for many years have not, believed in the real 
efficacy of the treatment by specific medicines during 
the active stage of any urethritis, no matter what its 
origin. And further, because I have long been satisfied 
that the treatment by so-called specific internal reme- 
dies is always more or less pernicious in its effect on the 
digestive functions, often producing dispepsia of a par- 
ticularly distressing and rebellious type. I have seen 
several cases of congestion of the kidneys brought on 
by the use of the balsam of copaiba in doses ordinarily 
prescribed. Mr. Milton (p. 69 of his work on gonor- 
rhoea) says of this drug : " In certain constitutions it 
brings on pain in the region of the kidneys, hematuria, 
severe headache, giddiness. The vomiting, too, it must 
be remembered, which copaiba brings on, is horrible, 
and few but the most resolute who have suffered in this 
way, can be induced to make a second trial," . . . and 
" these disagreeable results occur when copaiba is given in 



GONORRHCEA AND ITS SEQUELS. 297 

doses which very good surgeons have not hesitated to recom- 
mend." 

Formerly the abortive treatment of gonorrhoea by in- 
jections was approved and recommended by most au- 
thorities, and directions for its employment are still 
to be found in the latest text-books. It is instructive, 
however, to observe that the plan is now usually pre- 
sented with the distinct statement that its efficacy is 
more than doubtful, and that its employment is not with- 
out danger of aggravating the trouble. 

Thus, to quote from the latest English authorities, 
"the treatment of urethritis may be abortive or sys- 
tematic ; the abortive treatment includes methods of 
which the object is to cut short the disease before 
acute inflammation has supervened — that is, when the 
symptoms are confined to a tickling at the meatus and 
a slight clear viscid discharge. The various plans com- 
prise the injection of strong caustic fluids into the 
urethra and the administration of specifics such as co- 
paiba or cubebs in large and frequent doses. The suc- 
cess which follows the employment of either of these 
methods is so small, while the dangers that attend them 
are great, that we have abandoned them." (Hill and Cooper, 
London, 1881, p. 507.) 

Van Buren and Keyes (N. Y., 1874, p. 61), say that, 
" The idea of aborting gonorrhoea by the internal use 
of balsams has been abandoned. . . . The only allow- 
able abortive treatment, as far as the nitrate of silver is 
concerned, is its use at the strength of half a grain to 
the ounce, the injection being carefully repeated every 
two or three hours until a trace of blood is seen in the 
discharges. Then all treatment must cease. . . . As 
to the effect of attempts to cure by nitrate of silver 
treatment, it may be said that it very rarely succeeds 
if undertaken more than twenty-four hours after the 
commencement of the discharge .... (p. 62), when it 
does no good it invariably does harm. . . . In true gonor- 
rhoea there is no certainty of success in employing the 
abortive treatment. " From the above remarks it is 
evident that the abortive treatment is to be condemned, 
or at least only undertaken at the urgent request of the 



298 GONORRHCEA AND ITS SEQUELAE. 

patient, he being willing to assume all risks, and this 
course the judicious surgeon rarely accepts." Bumstead 
and Taylor (1879, P-48), sa y " During the first few days 
after exposure, from one to five, in different cases, before 
the symptoms have become acute, when the discharge is 
but slight and chiefly mucous, and while yet there is no 
severe scalding in passing water, we may resort to caus- 
tic injections, with the view of exciting artificial inflam- 
mation, which will tend to subside in a few days, and 
supplanting the existing morbid action, which is liable 
to continue for an indefinite period, and is exposed to 
various complications. This is known as the * abortive 
treatment' of gonorrhoea. ... It is certainly liable to 
be abused, and if so, is both unsuccessful and capable of 
producing the most unpleasant consequences ; but when 
limited to the early stage of gonorrhoea, and used with 
proper caution, it is a highly valuable method of treat- 
ment, unattended with danger and undeserving the cen- 
sure sometimes cast upon it." Again, p. 52, in closing 
the subject, they say, " I cannot leave the subject of the 
abortive treatment of gonorrhoea without again ex- 
pressly stating that I -recommend it only in the first 
stage of the disease, and not after the acute inflamma- 
tory symptoms have set in, or while the patient suffers 
from scalding in passing water." 

Thus it will be seen that Hill and Cooper include in 
the number of cases suitable for attempt at abortive 
treatment only those where the symptoms are confined 
to a tickling at the meatus and a slight clear viscid dis- 
charge. 

Van Buren and Keyes say that any attempt rarely suc- 
ceeds after 24 hours from the commencement of the 
discharge, and Bumstead and Taylor say that this plan 
should only be tried when the discharge is but slight, 
and chiefly mucous, and while there is no severe scald- 
ing on passing water. 

It will at once be seen that the symptoms above 
named are just and only those which characterize a 
simple urethritis, and that an assumption of its gonor- 
rhceal nature, based upon its alleged cure a few days 
subsequent to its administration of a caustic injection, 



GONORRHOEA AND ITS SEQUELS. 299 

followed by cessation of treatment, is simply to ignore 
the possibility of any other than a gonorrhceal origin 
for even the simplest forms of urethritis. 

I quite agree with Drs. Bumstead and Taylor in their 
statement, previously quoted, that the average duration 
of gonorrhoea is not less than four weeks, and I would 
go still further, and state it as my positive conviction 
and belief, based on a long and careful experience, that 
any urethral discharge which gets well within four weeks, 
under any sort of treatment, never was a true gonorrhoea. 
The current medical journals are teeming with medi- 
cines and injections, claimed to cure gonorrhoea in a 
week. Numbers of cases, giving an average cure in a 
few days, are reported. I do not question the honesty 
of purpose or statement in such cases ; the error lies in 
accepting all recent urethral discharges as gonorrhoea, 
without due investigation and without taking into con- 
sideration the fact that by far the greatest number of 
purulent urethral discharges are the result of other 
causes than the contagium of gonorrhoea. Notable 
among these is urethral stricture, from lithiasis, or from 
an antecedent gonorrhoea, occurring perhaps 10 or 20 
years previously, and thus often a cause wholly unsus- 
pected by the patient or physician. Of this character 
are the gonorrhoeas, which many patients aver that they 
get, every time they have a suspicious connection. 
These are the cases which make the reputation of numer- 
ous medicinal preparations, soluble bougies, and more 
numerous injections, which are warranted to cure 
gonorrhoea in a few days, and not unfrequently do so, 
if we are willing to accept as a gonorrhoea a purulent 
discharge following connection, in a case where a strict- 
ure of the urethra is present. 



300 GONORRHOEA AND ITS SEQUELS. 



LESSON XXXV. 

Gonorrhoea claimed to be due to a specific contagium — the so-called gonor- 
rhoeal bacillus — Tenacity of life in such organisms forbid the possi- 
bility of their destruction by any measures which are suitable for use — 
Ordinary antiphlogisic remedies alone promise benefit — The author's 
method of treating gonorrhoea in the early stage — Systematic treat- 
ment of gonorrhoea as recommended by authorities. 

Gonorrhoea is claimed, by some, to be due to a specific 
contagium; by others to be a simple urethritis, capable 
of being set up by various causes, and of being aggra- 
vated by conditions, and applications, which have a ten- 
dency to induce irritation, inflammation, and disease, 
in healthy structures. If those who accept the latter 
view are correct, the attempt to abate an inflammation 
through means which practically increase it, is appa- 
rently idiotic. 

If, on the other hand, a distinct contagium, a " gonor- 
rhceal bacillus," is claimed, it will be interesting for those 
who still occasionally practice the abortive method, to 
consider the fact that such barillas flourish and propa- 
gate in caustic solutions of a strength which promptly 
destroys human tissues, and that persistent immersion 
in boiling water (220 Fahrenheit) for twenty-four hours, 
has been proven not to interfere in the smallest degree 
with their vital activity or their contagious properties. 

The plan of treatment I invariably pursue, in cases 
of alleged commencing gonorrhoea, is, in the first place, 
to explain as concisely and emphatically as I am able 
the impossibility, under any conceivable circumstances, 
of averting the disease, whatever it may prove to be. 
Next, to explain the different ways by which such a 
discharge may have been caused, and, at the same time, 
gain such information in regard to the probable cause, 
as the patient might be able to afford. Then, if the 
source of the discharge is not found unmistakably of 
stricture origin, to insist upon absolute rest upon the 
back — best in bed, soaking the penis frequently in water 



GONORRHCEA AND ITS SEQUELS. 30I 

as hot as can well be borne, especially placing the 
penis in water of a temperature not less that ioo° dur- 
ing every act of urination. Besides this, to clear the 
bowels with a calomel purge, and administer 10 grains 
of the bi-carbonate of potassa, and 10 grains of the 
acetate of potassa, either in a large cup of flaxseed tea, 
or a glass of Vichy water, every four or six hours. If 
I cannot, through energetic statement of the possible 
consequences of neglecting the above plan, succeed in 
having it followed, de rigueur, I come as near it as I can, 
and with the result in at least 50 per cent of all the 
cases presenting, of demonstrating, first, that the disease 
is not a true gonorrhoea ; and second, of relieving, in a 
few days, all the inflammatory conditions in the cases, 
thus shown not to be true gonorrhoea, and putting them 
in the line of permanent cure, addressed to causes and 
conditions which may be shown responsible for the 
initiation and continuance of the trouble ; and third, 
in those cases which are proved to be gonorrhoea, the 
foregoing measures will have reduced inflammatory 
symptoms where any other course must of necessity 
aggravate them, and thus place the patient in the best 
possible position to secure the least discomfort, and the 
shortest duration of the remaining periods of the disease. 



302 GONORRHOEA AND ITS SEQUELS. 



LESSON XXXVI. 

SYSTEMATIC TREATMENT OF GONORRHOEA. 

Usual method of treating gonorrhoea in America — Drs. Bumstead and 
Taylor's plan — Plan of Drs. Van Buren and Keyes — The latter dwell 
on the importance of hygienic management — Alkalies alone in the in- 
creasing stage, then copaiba and cubebs — Use of injections highly 
commended in stage of decline — Illustrative formulae — Drs. Bumstead 
and Taylor begin with general measures — Brisk cathartics — Early and 
frequent local applications of hot water according to Mr. Milton's 
plan — Copaiba and cubebs given early in the disease — Injections in 
variety — In the stage of decline — In the third stage, injections — Copai- 
ba and cubebs, etc. — Illustrative formulae — Addendum — Dr. Curtis's- 
method of treatment of gonorrhoea by hot-water retrojections — Dr. F. 
R. Sturgis's views — Author's suggestions. 

Having eliminated all elements of doubt in a case of 
recent, more or less acute, urethral discharge, and after 
ascertaining that, in spite of your precautionary and 
soothing measures, the urethral inflammation steadily 
progresses; that the pain and swelling increase, and the 
discharge becomes more profuse, assuming a yellow or 
greenish hue, it must be practically accepted — no mat- 
ter what its origin— as a typical case of gonorrhoea, and 
treated as such. Before presenting my own views and 
practice in the management of acute gonorrhoea, I will 
briefly summarize the prevailing views and modes of 
treatment. 

According to American authorities we may accept 
Bumstead and Taylor, 1879, as tne latest, and Van 
Buren and Keyes as the one immediately preceding, 
published in 1874. Each is generally accepted as repre- 
senting the most advanced and judicious mode of man- 
agement at the date of publication. Thus, Van Buren 
and Keyes, under the head of the methodic treatment 
of urethral inflammation, say : "■ The hygienic part of 
the treatment is of the utmost importance . . . absolute 
continence . . . avoidance of anything liable to induce 
sexual excitement ... no alcoholic stimulants of any 



GONORRHOEA AND ITS SEQUELS. 303 

sort, particularly no sweet fermented wine (champagne), 
and above all no malt liquor. Abstinence from salt and 
highly-seasoned food, coffee, asparagus, etc., (quoting 
Fournier). " All violent exercise must be avoided. 
Utmost cleanliness in all respects is obligatory." 

Of the increasing stage " the first and perhaps only 
medicine the patient need take internally is an alkali." 
The following prescription is given as an example : 

B- Potass. Citratis § ss-i 

Spirits limonis 3 ss 

Syrup simplicis § ij 

Aquae . |i 

A dessertspoonful largely diluted with water, three or four times 
daily, fasting. 

Vichy water, etc. 

" More or less of this or of some other alkaline prepa- 
ration should be continued throughout the treatment. 
If micturition is quite painful, grs. i. to iii. of the ex- 
tract of hyoscyamus may be added to each dose of the 
alkali. 

" Then, with first stage of gonorrhoea, capsules of bal- 
sam of copaiba, or oil of yellow sandalwood, ten drops 
in each." Then follows the Lafayette mixture and two 
corresponding formulae, and on page 69 (ibid.), they say 
the " balsam of copaiba is the best preparation and is 
applicable to all stages of the disease. . . . Oil of yellow 
sandal-wood is a most excellent remedy : in some cases 
certainly doing better than copaiba. . . . Oleo-resin of 
copaiba is usually well borne by the stomach. . . . 
These three remedies may be alternated, commencing 
with sandal-wood, and ending with cubebs. The last 
one in use when the discharge has ceased, should 
be continued for at least ten days, one capsule less 
being taken daily, until the remedy is gradually drop- 
ped." 

Of local measures they say (page 65, ibid.): 

"Injections are of doubtful advantage in the increasing 
stage of gonorrhoea. In bastard gonorrhoea and mild 
urethritis they are of great importance from the first. 
If a diagnosis of either of the latter conditions can be 



304 GONORRHOEA AND ITS SEQUELAE. 

made, one of the following injections may be made at 
once/' thus : 

"Sf Liq. Plumbi Subacetatis, dil | i 

Ext. Opii Aquos grs. vi 

M., et cola. 

Also at p. 69, ibid. : " Injections are of great service 
in the stage of decline ; any of the formulas on page 
65 may be used, commencing with the milder and end- 
ing with the stronger solutions," thus (p. 65): 

(1) 1$ Zinci Sulphatis grs. i-iii 

Liq. Plumbi Subacetatis dil § i 

Shake before using. 
M. 

(2) 1$ Zinci Sulph grs. i-iii 

Aquse § i 

M. 

(3) 1^ Acid. Tannic grs. v-x 

Aquae § i 

M. 

(4) 3 Aluminis Exsic grs. vi-x 

Aquse §i 

M. 



Drs. Bumstead and Taylor begin the treatment of 
gonorrhoea in the acute stage with a brisk cathartic,* 
" five grains of calomel combined with ten grains jalap ; 
a full dose of Epsom salts or three or four compound 
cathartic pills of the U. S. P." " Water as hot as can 
be borne is the most grateful application that can be 
used. I have found that it generally affords relief to 
the scalding in micturition, and the local pain and un- 
easiness, and can fully endorse Mr. Milton's views in 
regard to it.". . . After the operation of the cathartic 
we may, in most cases, commence at once with copaiba 
or cubebs." When, however, there is much swelling 
and severe pain on urinating, it is advised that the anti- 

* Bumstead and Taylor, fourth edition, 1879. Henry C. Lea, Phila- 
delphia. 



GONORRHOEA AND ITS SEQUELAE. 305 

blenorrhagics be deferred for a few days, using alkalies 
and sedatives instead, thus. 

I£. Potass Bicarbonatis § i 

Tr. Hyoscyami f i 

Mucilaginis | ii 

M. 

A teaspoonful every four hours. 

While the case is severe, the above constitutes the sole 
treatment. When the local symptoms are not severe, 
so that the syringe can be used without pain, an opiated 
and demulcent injection is recommend, thus : 

Ifc. Extracti opii 3i 

Glycerinae % i 

Aq §iii 

M. 

" Injection to be used after every passage of urine." 
Subsequently, " half a drachm of Goulard's extract, as 
the inflammatory symptoms begin to subside," 

Of " the treatment of the stage of decline" they say 
(P- 57) f " The chief remedies adapted to the third stage 
of gonorrhoea are injections and copaiba and cubebs. 
By far the most important of these are injections, which 
constitute our chief reliance in the treatment of this 
affection when it has arrived at this stage. . . . Under 
certain circumstances their effect is found to be injurious. 
If, in the course of treatme7it, the patient complains 
of a frequent desire to pass his urine, and other symptoms 
indicating irritation or inflammation of the neck of tJie 
bladder or prostate* injections should at once be suspend- 
ed." A large number of formulas are given for copaiba 
and cubeb mixtures, the following of which may serve 
as a type (the Lafayette mixture, p. 66) : 

1$. Copaibae |i' 

Liquoris Potassse 3 ii 

Ex. Glycerrhizae z ss 

Spiritus vEtheris Nitrici | i 

Olei Gautheriae gtts. xvi 

M. 

Dose: a tablespoonful after each meal. 

* Italics are my own. — F. N. O. 



306 GONORRHOEA AND ITS SEQUELAE. 

Ibid., p. 6? : 

Pulveris Cubebac § iii 

Copaib fiss 

Aluminis 3 ii 

Sacchari albi | i 

Magnesise 3 iss 

Olei cubebse 

Olei Gautherise aa 3 i 

This mixture is known as the black paste, and the 
patient is directed to take a piece the size of a walnut 
after each meal. 

Capsules containing" cubebs and copaiba also recom- 
mended (p. 71) : " During the administration of copaiba, 
cubebs, or any other drugs which act by their presence 
in the urine, the patient should drink but little fluid so 
that the urine may be undilated, and as fully charged 
as possible with the remedy." 

Addendum. 

A new method for the treatment of gonorrhoea and gleet 
has been very recently brought to my notice through 
an article entitled " The Hot Water Retrojection in the 
Treatment of Gonorrhoea," by Dr. Holbrook Curtis, of 
New York, published in the New York Medical Record 
of April 21, 1883. This plan is so much in line of my 
own view of the essential requirements in such cases, 
that it has seemed to me desirable to present it, not only 
because it claims better results than any plan with which 
I have had practical acquaintance, but because it sup- 
ports the non-specific view of the disease, and is in har- 
mony with rational medicine, hence opposed to specifics 
in the treatment of the disease. Thus he says : 

" Endoscopic examination reveals that a current of 
hot water passed continuously through the urethra pri- 
marily congests and secondarily renders anaemic the 
mucous membrane, in the same way that a hot bath 
affects the fingers. It is observed also that the urethra, 
after being acted on for some time, will endure water 
of a temperature that cannot be tolerated by the hand. 
Taking advantage of 'this fact, I have arranged an ap- 
paratus by means of which one is enabled to pass seve- 



GONORRHOEA AND ITS SEQUELS. 7>°7 

ral quarts of hot water through the urethral canal from 
the prostatic portion outward, increasing all the time 
the temperature of the water until the thermometer oft- 
times indicates 180 to 190 F. I have repeatedly passed 
ten quarts of water from behind forward in this manner, 
continuing the retrojection for some time after the point 
of toleration has been reached. This varies much in 
different persons. It remains then to pass a mild astrin- 
gent solution through the same catheter that has been 
employed for the retrojection. Preferably I use a sus- 
pension of iodoform in a glycero-tannin solution in the 
following proportion : 

]$. Acidi Tannici, 

Iodoformi 58 3ii 

Glycerinse § i 

Aquae | iii 

Sig. : Heat, shake, and inject. 

After the injection the catheter is withdrawn and the 
patient is directed to return in twelve or twenty-four 
hours, as the case may warrant. . . . 

" In twelve cases of undoubted acute gonorrhoea the 
discharge has been entirely checked in three days. In 
two cases I have succeeded in aborting the disease by 
one prolonged (ten quarts) thermo-retrojection. In six 
cases the disease lasted six to ten days, while a case of 
chronic gleet that had made the round of the profession 
for nine months succumbed in seven days to dilatation 
and retrojection. 

" It has been noticed that cases that have been treated 
for some time with strong mineral injections do not re- 
spond nearly as quickly to the hot-water method. I 
have yet to see, however, a ' fresh case ' of gonorrhoea, 
in which no previous injection has been employed, that 
will not recover within a fortnight if the retrojection is 
properly administered. 

" From a careful study of more than forty cases, I claim 
for hot retrojection : 

" First. The course of the disease is shortened, by at 
least two thirds, making the average limit of the case — 
viz., stoppage of the discharge — nearer one week than 
three. 



308 GONORRHCEA AND ITS SEQUELAE. 

" Second. The discharge immediately changes from a 
purulent to that of the nature of gleet, and is reduced 
to a very small quantity. 

" Third. There is absence of chordee and pain in pass- 
ing urine. 

" Fourth. Stricture as a sequel is improbable. 

" Fifth. The usual inconveniences of the disease are 
done away with. 

" A brief description of the apparatus employed is as 
follows : An ordinary wooden armchair is half-mooned 
in the front of the seat to admit a tall cuspidor. A 
pulley is rigged on the ceiling by means of which a tin 
pail with a lamp beneath is elevated. A rubber tube, 
provided with a stopcock and connection, leads from the 
pail, and at any time may be fitted to an ordinary No. 
8 English flexible catheter. The necessity of having a 
catheter with a bulbous end to prevent water passing 
into the bladder is purely imaginary. I would also state 
that an ordinary Davidson's syringe may be used, the 
patient giving himself the retrojection from the pail on 
a chair beside him ; this is not as convenient, however, 
as the gravity apparatus. When the water is of the 
proper temperature, say 120 F., the catheter is vase- 
lined and introduced to within an inch of the prostate, 
connected with the rubber tubing, and the pail elevated 
to such a height that the flow is brisk. The lamp under 
the pail will keep the temperature of the water slowly 
increasing. The patient holds the catheter in position, 
and may read the morning paper until the water be- 
comes uncomfortably hot. The lamp is then extin- 
guished, and the retrojection proceeds at the point of 
toleration. After this has gone on for a sufficient time, 
a syringeful of the injection formulated above is thrown 
in, and the catheter is withdrawn. If the patient is un- 
able to come back at once, give him the same prescrip- 
tion for urethral injection, or slightly modified to suit 
the particular case, with directions to use it twice a day 
until he can return. As an adjunct to this the only in- 
ternal treatment I employ is bicarbonate of soda in five- 
grain compressed tablets, to take ten daily. Hereto- 
fore my cases have been confined to private practice, 



GONORRHOEA AND ITS SEQUELS. 309 

but recently, at the kind invitation of Professor Sturgis, 
I had an opportunity to demonstrate this method at the 
Charity Hospital, where I am told the results have been 
so gratifying that Dr. Sturgis has promised to compile 
the statistics in regard to this mode of procedure, which 
seems so rational that it will undoubtedly supersede the 
ordinary injection treatment. 

" Several writers have advocated warm water ' irri- 
gation ' of the urethra in gonorrhoea, and have claimed 
more or less success for their methods, but no one, to 
my knowledge, has shown any statistics that can com- 
pare with those obtained by prolonged progresso- 
thermal retrojection. More than a brief outline of the 
subject would be too lengthy for an article of this kind, 
but there is such a field for experiment afforded in this 
direction, I take this opportunity of placing some frag- 
mentary data before the profession." 

I have taken the pains to ascertain from Prof. F. R. 
Sturgis, one of my colleagues in Charity Hospital, the 
results of his experience in the method of treatment of 
gonorrhoea above cited. He informed me that the hot- 
water retrojections, as proposed by Dr. Curtis, were 
readily applied and well borne in several cases at Char- 
ity Hospital, as well as in his private practice, and that 
in no case had any unpleasant effects been recognized. 
On the contrary, the inflammation had been promptly 
lessened by every injection, and that the discharge had 
proportionately decreased. While he was very favor- 
ably impressed with his experience with the hot-water 
retrojection plan, he had not yet had sufficient experi- 
ence to speak otherwise than tentatively of the matter. 

Without any practical experience in this very flatter- 
ing mode of treatment as thus far presented, it occurs 
to me that it is open to at least two objections. First, 
that the depth to which the injection is advised is un- 
necessary, as the occurrence of gonorrhoea, as far back 
as the prostate, in my opinion is not met with practi- 
cally once in five hundred cases. Hence, irritation of 
the deep urethra, and possible extension to the seminal 
apparatus, readily resulting in epididymitis, is not war- 
rantable. I have cited several cases where acute pros- 



3IO GONORRHOEA AND ITS SEQUELS. 

tatic inflammation has apparently resulted from a simi- 
lar mode of administering copious injections of moderate 
temperature. Again, the danger of throwing the injec- 
tion into the bladder is not a fictitious one. I have seen 
several cases where the bladder has been easily filled 
and refilled over and over again with the short pipe of 
an ordinary Davidson's syringe. Again, I would ob- 
ject to the brisk flow of the fluid as introducing an 
unnecessary element of force, which on general prin- 
ciples should be eliminated, as far as practicable, from 
all operations and procedures involving the genito- 
urinary apparatus. A gentle, steady current would, it 
appears to me, produce equally good results without the 
danger of forcible distension of the deep urethra. These 
points, while they seem to me important to recognize, 
are yet susceptible of easy correction without detract- 
ing from the efficiency of the method which in the 
main appears to me most promising, and which, with 
water of a temperature of 120 F., I shall not hesitate 
to give an early and thorough trial. 



GONORRHCEA AND ITS SEQUELAE. 311 



LESSON XXXVII. 

Usual method of treating gonorrhoea in Great Britain, by Messrs. Hill 
and Cooper — Cold rather than hot applications are recommended — Spe- 
cifics not given in the first stages — Injections rarely to be used until 
the acute inflammation has subsided — Formulae given much the same 
as previously quoted from American authorities — Treatment in vogue 
at King's College Hospital, London — St. Mary's Hospital — University 
College Hospital — Middlesex Hospital — Expectant treatment. 

Of the English authorities, we have, latest, Hill 
and Cooper.* In the first place, in commencing 
the treatment of gonorrhoea, they agree precisely 
with Van Buren and Keyes, as to the impor- 
tance of hygienic treatment and the mode of carrying 
it out. Alkaline and demulcent drinks, with a saline 
aperient every morning. Warm baths half hour at a 
time at 95 F. (p. 509 ibid.). Advise that penis be wrap- 
ped in strips of rag dipped in warm water and covered 
with oiled silk or ice-water, whichever gives most 
relief. Otis's coil with cold water current. If pain very 
severe 15 or 20 leeches to perineum. 

No injections have been found by them serviceable 
during inflammatory stage, except two, viz., half-hourly 
injections of tepid water into urethra which sometimes 
give relief, but often none. If congestion be moderate, 
hourly injections of alum or sulphate of zinc, quarter 
grain to the ounce. Painful micturition best relieved by 
alkaline drinks, warm baths, rest and local depletion. 
Injection of ice-water into urethra before micturating, 
or immersion of penis during the act, often effectual 
in easing pain. 

Of specifics they say (p. 513): "The good effect of 

*" Syphilis and the Local Contagion Disorders." London. Second 
edition, 1881, p. 508. 



312 GONORRHCEA AND ITS SEQUELS. 

copaiba depends almost entirely on its being given 
when the mucous membrane is ready for it. If given too 
early, it fails to do good, and sometimes does harm. 
The urethra is in the most favorable condition for 
copaiba when the pain on passing water is nearly gone, 
when the painful erections are nearly at an end, when 
the discharge has become less in quantity, etc. . . . 
Much pain in passing water is always a sign that 
specifics will do harm." Cubebs, oil of yellow san- 
dal-wood, Gurgun balsam, balsam Peru, and Chian 
turpentine believed occasionally to have been useful; 
also, oil of ergeron. Kava kava, suggested ; not yet 
tried. 

In regard to injections they say : 

" Recourse should be rarely had to them (p. 517), 
until the acute inflammation nas nearly subsided ; and 
they are most effective when given to complete a cure 
that has already made progress by other means." 
Formulae for several, practically the same as recom- 
mended by authorities already quoted: 

Mr. J. L. Milton, of London, who has written a work 
of over three hundred pages on the subject of gonor- 
rhoea and its complications, in the fourth edition, in 
1876, gives a summary of the views of practice in 
gonorrhceal disease in Great Britain, and wHile his own 
views are generally in accord with those quoted from 
authorities in this country and in England, previously 
cited, he very evidently has not their faith in the 
necessities or in the efficacy of injections or specifics in 
the treatment of the disease. He presents the plan of 
management in the different hospitals of London.* 
Thus — 

In Guys Hospital. — Mr. Bryant gives scruple or half- 
drachm doses of tartrate of potassa, adding, when weak- 
ness is present, potassio-tartrate of iron and tincture of 
the muriate of iron. He has given up injections, but 
in some cases introduces a concentrated solution of 
tannin into the urethra by means of a bougie. 

London Hospital. — M. Maunder gives a mixture of 

* Condensed from reports published in the London Lancet in 1S67. 



GONORRHOEA AND ITS SEQUELS. 313 

copaiba, liquor potassae, spirit of nitric aether and cam- 
phor julep. In the acute inflammatory stage a scruple 
of nitrate of potass, with or without an eighth of a 
grain of tartar emetic and morphia, every four hours, 
night and day. An occasional purge is ordered. For 
gleet he prescribes twenty drops of tincture of muriate 
of iron thrice daily. In private practice he prefers 
injections of sulphate of zinc and treatment on general 
principles. 

St. Bartholomew s Hospital. — Injections of sulphate of 
zinc two grains to an ounce. When there is much 
inflammation this is first of all allayed by means of 
warm fomentations, warm baths, opium, or a supposi- 
tory of morphia. Free action of the bowels is main- 
tained. Diluents are prescribed. This treatment is 
described as almost invariably successful. Should it 
fail, the local application of bougies and the counter- 
irritant effects of blisters applied to, or nitrate of silver 
rubbed over, the front of the upper part of the thigh, 
Scarpa's triangle, are found the most efficient remedies. 
Orchitis is treated with opium, rest, and linseed poul- 
tices. 

Kings College Hospital. — Mr. Wood, in the acute stage, 
gives a saline aperient, or a drachm of compound jalap 
powder, or a drachm of jalap and calomel if the patient 
be bilious, at intervals of three or four days, or a week, 
during the treatment. Afterwards he gives liquor 
potassas or bicarbonate of potassa in camphor mixture 
or infusion of pareira, with plenty of diluents. He 
prescribes early and frequent injections of lead lotion 
and glycerine. For orchitis he punctures the tunica 
albuginea. To allay chordee he uses compound hen- 
bane pills, or in severe cases morphia or chlorodyne, 
aided by the local application of iced water. 

In the chronic stage, while the discharge is profuse, 
Mr. Wood gives copaiba and sulphuric acid, with 
frequent injections of sulphate of zinc, alum, or nitrate 
of silver ; in obstinate cases powdered cubebs in drachm 
doses. In sluggish cases, with gleety discharge, tonics, 
mineral acids, and especially tincture of sesquichloride 
of iron in twenty-minim doses, three times a day. If 



314 GONORRHOEA AND ITS SEQUELAE. 

the discharge become gleety or thin, injections of a 
weak solution of chloride of zinc, or perchloride of 
iron and glycerine. Sometimes he employs the same 
substances in the form of a soluble bougie or uses 
matico. 

St. Marys Hospital. — The treatment of the late Mr. 
Gascoyen is described as consisting of weak astringent 
injections in the very early stage, but not when the 
symptoms had become severe, preference being then 
given to copaiba in doses of forty to sixty drops daily. 
For ardor urinae, irritability of the neck of the bladder 
and chordee, if severe, suppositories of soap and opium. 
After the violence of the symptoms had passed off 
weak injections might again be employed, along with 
drachm doses of cubebs when the discharge was very 
obstinate ; after this quinine, tincture of iron, and other 
tonics. He considered salines and depleting means in 
the early stages not only useless but injurious, and he 
scarcely ever knew abortive treatment succeed, while 
he often saw gonorrhoea exasperated by it. 

Charing Cross Hospital. — Mr. Barwell avoids copaiba. 
In a first attack he purges, orders hot bathing, diuretic 
or aperient alkalies as may be indicated, followed by an 
injection of sulphate of zinc, two grains to an ounce. 
For second or subsequent attacks, free use of aperi- 
ents and injections; chronic cases may be treated with 
tannic acid injections, three or four grains to an ounce. 
For slight but continuous discharge, either Chian tur- 
pentine or Canada balsam, with black or cayenne pep- 
per. He often finds tincture of steel and tincture of 
capsicum useful. Cubebs is not better than the other 
peppers. The most certain and efficacious treatment 
is to pass down every other day, for an inch or an inch 
and a half, a bougie smeared with an ointment contain- 
ing three, five, or even ten grains of nitrate of silver to 
an ounce of lard. 

University College Hospital. — Mr. Christopher Heath, 
in the early stage, injects from the very beginning a 
strong lead lotion, an ounce of the liquor plumbi to 
seven of water. In the ordinary acute form he pre- 
scribes injections of warm water and weak lead lotion, 



GONORRHCEA AND ITS SEQUELS. 315 

followed by sulphate of zinc injections when the acute 
symptoms have subsided. Rarely gives copaiba. For 
chordee, extract of belladonna and glycerine applied to 
the under surface of the penis, with a pill of opium or 
henbane at night. He finds acute orchitis yield readily 
to antimony and sulphate of magnesia. When there is 
much oedema, he punctures the tunica vaginalis. Later 
on, strapping and mercurial ointment remove any en- 
largement of the testis. In gleet he examines the 
urethra with the bougie and endoscope, and if, as 
frequently happens, he discover a distinctly diseased 
surface, a strong solution of nitrate of silver is applied 
topically; if the disease appear to be more general, an 
astringent injection is given, a large metal bougie 
passed and steel prescribed. 

Middlesex Hospital. — In the early stage Mr. Hulke 
prescribes an injection of acetate of lead frequently 
repeated, and purges freely, generally giving compound 
jalap powder. In the more chronic condition he orders 
frequent injections of one grain of nitrate of silver to 
eight ounces of water. For old gleets copaiba or 
cubebs, more frequently, however, tincture of sesqui- 
chloride of iron. In acute orchitis, Mr. Hulke prescribes 
nauseating doses of tartar emetic with Epsom salts, and 
sums up as follows : " In the pages the reader has 
just passed through, eight different systems of treat- 
ment are found to prevail in as many different hospitals, 
all adopted and put in force by able and experienced 
surgeons. What is more, my inquiries lead to the 
conclusion that, had the number of hospitals reported 
upon been multiplied tenfold, the result would have 
been to display ten times as many different methods." 
He also quotes the views and plans of Mr. Chalmers 
Miles, who advocates extensive blistering of the thighs 
as the sole remedy in gonorrhoea, claiming cure by this 
method in five to six days, citing an experience in sixty 
cases (p. 60, ibid.). On page 62 he refers to treatment 
without specifics, or injections, or blisters, thus : 

" The Expectant Treatment. — This system has at one 
time or other had advocates of such capacity that it 
cannot be passed over. Not long ago it found an able 



316 GONORRHOEA AND ITS SEQUELAE. 

champion in Dr. Chambers, of St. Mary's Hospital. 
This gentleman, as I understand him, says that gon- 
orrhoea is naturally a most mild disease both in the 
male and the female, and if left to itself will get well in 
a short time, occasionally in four or five days, while the 
simplest treatment will remove it in a fortnight if it be 
not made severe by the folly of the patient or his medi- 
cal attendant. "I consider," he says, "all primary 
heroic treatment of urethral discharges a most unjustifi- 
able interference with nature." Of this plan Mr. Milton 
says, " It is not very easy to imagine how any one 
could argue in favor of a more hopeless cause. There 
is no evidence brought forward in support of a state- 
ment which runs quite counter to the experience of the 
greatest men who have studied the disease. What 
they, after mature deliberation, say, utterly negatives 
the idea of gonorrhoea being so easily managed by the 
simple process of letting it alone." 



GONORRHOEA AND ITS SEQUELS. 



317 



LESSON XXXVIII. 

Mr. Milton's statistics of the results of the treatment of gonorrhoea by 
balsam copaiba — Cases treated by rest and abstinence — Treatment by 
purgatives — Popular appreciation of the value of copaiba — Mr. Mil- 
ton's views of the treatment of gonorrhoea by injections — He does not 
accept statements of their great efficiency — List of articles recom- 
mended as curative — Over fifty articles selected to represent the varie- 
ties of injections in common use — Accuracy as to their comparative 
value, in Mr. Milton's opinion, not possible — Mr. Milton's experience 
in the use of injections — Their power as curative agents very limited — 
His statistics show an average continuance of gonorrhoea, under any 
treatment, of over four weeks — His opinion of the use of copaiba — He 
claims that it should be banished from the therapeutics of gonorrhoea. 

Mr. Milton gives his own statistics of results of treat- 
ment by balsam copaiba, which are so interesting in 
view of the claims for the great curative properties 
of copaiba in the treatment of gonorrhoea, generally 
accepted, that I shall quote them entire, from page 70 
et seq.: 

CASES TREATED WITH COPAIBA. 





Initials. 


Nature of Case. 


Treatment. 


Result. 


I 


J. D. 


Mild gonor- 


Copaiba. Injections 


Not quite cured at 






rhoea of three 


of sulphate of zinc 


end of 27 days. 






months' dura- 


and nitrate of sil- 








tion. 


ver. 




2 


W.J. 


Gonorrhoea of 


Potassio - tartrate of 


At the end of 86 days 






three or four 


antimony, copaiba, 


left off attending. 






days' stand- 


turpentine, and 


Not quite cured. 






ing. 


steel. 




3 




Gonorrhoea of 
three days' 
standing. 


Pulv. salin. At the 
end of fourteen 
days copaiba, and 
then turpentine. 
Afterwards colchi- 
cum. 


Cured in 65 days. 


4 


J. S. 


Ordinary gon- 


Had been treated for 


At the end of this 






orrhoea. 


seven months with 
sulphate of magne- 
sia, copaiba, etc. 


time he was still 
suffering from 
gleet, cloudy urine, 
and pain over the 
bladder. 



318 GONORRHCEA AND ITS SEQUELS. 

CASES TREATED WITH COPAIBA. — Continued. 





Initials. 


Nature of Case. 


Treatment. 


Result. 


5 


L. H. 


Gonorrhoea of 
a month's 
standing. 


Injections and pur- 
gatives for fourteen 
days. Pulv. salin. 
and inject, of sulph. 
of zinc. Copaiba, 
turpentine, and 
pulv. salin. Injec- 
tions. 


Cured in 52 days. 


6 


W. 


Gonorrhoea of 


Magnes. sulph., fol- 


Not quite cured at 






a week's dura- 


lowed by copaiba 


the end of three 






tion. 


and nitrate of pot- 
ass. Injections of 
sulph. of zinc. 


months. Subse- 
quently he reports 
that the disease 
died out without 
anything further 
being done for it. 


7 


J. W. 


Gonorrhoea of 


Aperients and co- 


Rapid improvement. 






some days' 


paiba perseveringly 


Severe relapse, ap- 






standing. 


used for seven 
months. 


parently from ba- 
thing. At the end 
of 7 months scarce- 
ly well. 


8 


Mr. N. 


Gonorrhoea, se- 


Copaiba, liquor pot- 


Cure twice deferred 






cond attack, 


assse, compound ca- 


by his giving up 






very severe. 


lomel pill at night. 


treatment just as 
he appeared to be 
getting quite well. 


9 


Mr. R. 


Gonorrhoea of 


Copaiba and liquor 


Discharge removed 






four days' 


potassae with five 


in 3 months. 






standing, 


grains of blue pill 








complicated 


every night for a 








with a sore on 


short time. Injec- 








the penis. 


tions of nitrate of 
silver and sulph. of 
zinc. 




10 


Mr.W. 


Gonorrhoea of 


Copaiba, cubebs, zinc 


Little improvement 






a fortnight's 


injections. Almost 


at the end of 12 






standing; first 


constant rest. 


weeks. 


ii 


Mr. E. 


case. 
Gonorrhoea of 


Brisk purgatives, co- 


Cured in about 7 






four days' 


paiba, liquor potas- 


weeks. 






standing; sec- 


sae, pil. hydrarg. 








ond attack. 


chlor. comp. Injec- 
tions of arg. nit. 
and zinc, sulph. 




12 


Mr. B. 


Gonorrhoea of 


Copaiba, liquor pot- 


At the end of 2 






some weeks' 


tassas, compound 


months still some 






standing. 


calomel pill. 


gleet remaining. 



GONORRHOEA AND ITS SEQUELAE. 319 

CASES treated WITH COPAIBA. — Continued. 





Initials. 


Nature of Case. 


Treatment. 


Result. 


13 


A. T. 


Ordinary gon- 


Took six drachms of 


Still some purulent 






orrhoea. 


copaiba, and the 
same amount of 
spirit of nitric 
ether, every week 
for one year. 


discharge remain- 
ing at the end of 
that time. 


14 


Mr. H. 


Ordinary gon- 


Took two pints of 


No better at the end 






orrhoea. Pa- 


copaiba in two 


of the time. 






tient very 


months, under the 








delicate. 


care of an experi- 
enced surgeon. 




15 


C. S. 


Simple gonor- 


Took half a pint of 


Discharge dimin- 






rhoea. 


copaiba a month 
for four months. 


ished to a very 
small amount; re- 
turned directly on 
the copaiba being 
left off. 


16 


Mr. F. 


Rather severe. 


Copaiba in small 


Little if any im- 






Patient him- 


doses, and then an 


provement at the 






self a sur- 


ounce daily for 


end of this time. 






geon. 


above two months. 


1 



He also quotes (page 66), the results of treatment of 
gonorrhoea by rest and abstinence alone, 1 5 cases, with 
cure, varying from three to twenty-three days, and an 
average of eight and one half days. 

Eight cases treated with cubebs alone, with an aver- 
age cure of five and one half days ; ten cases treated with 
capsicum, with an average cure of thirteen and one half 
days ; three cases treated with camphor, with an average 
of nine days. 

Treatment by Purgatives (page 24, et sea., ibid.) : One in 
sixteen days, one in twenty-eight days, one in forty- 
seven days, one on the thirty-fifth day a stricture dis- 
covered — cure in two months by bougies. 

Eight cases treated by aperients alone : four cured at pe- 
riods varying from three to forty-five days, one in three 
days, one in sixteen days, one in thirty-seven days, with 
slight gleet remaining cure in eight days by tincture. 

An interesting fact, showing the popular appreciation 
of the value of copaiba, is presented on page 70, where 



320 GONORRHOEA AND ITS SEQUELS. 

he says : " My own experience has satisfied me that the 
practice of giving it is very extensively diffused, and 
Mr. Weeden Cooke confirms this. On inquiry at the 
London Custom House, he found that during the first 
ten months of the year 1859 no ^ ess than 118,396 pounds 
of copaiba were admitted, or at the rate of 151,075 
pounds annually — a quantity sufficient to supply five 
hundred thousand people every year with a strong dose 
three times a day for nearly four weeks ! 

In regard to treatment of gonorrhoea by injections, 
Mr. Milton evidently distrusts much that has been 
claimed for many varieties ; on page 107 et seq. he says : 
" A list of the substances recommended for injections 
within the last few years would perhaps show, more 
strongly than anything I could say, the discrepancy of 
opinion that prevails as to which is the best. I therefore 
give a selection : chloride, tannate, and acetate of zinc, 
carbolate of zinc, sulphocarbolate of zinc, sulphate of 
zinc, curing as a rule on the third or fourth day, or even 
sooner ; nitrate of silver ; acetate of lead ; sulphate 
and chloride of copper; the four sulphates (a com- 
bination of alum, zinc, iron, and copper) ; iodide and 
potassio-tartrate of iron, iodide of iron in combina- 
tionwith iron filings, tincture of sesquichloride of iron, 
solution of perchloride of iron, solution of persul- 
phate of iron ; oxychloride of tin combined with phos- 
phate and tannate of tin ; trisnitrate of bismuth ; per- 
nitrate of mercury, perchloride of mercury ; chloride 
of soda ; chlorate of potass, carbolate of potass, car- 
bolic acid and potass, permanganate of potass, which 
was said to cure recent attacks of the disease in from 
one to two days, and only failed twice in 64 cases, be- 
ing just one day less than was requisite to effect a cure 
with the chlorate of potass ; Condy's fluid ; alum, tan- 
nate of alumina, succeeding, according to one author, 
where all the usual injections had failed, and described 
by another as not more efficacious than other kinds of 
injections ; chloride of lime, bisulphite of lime ; tincture 
of iodine, recommended as having never failed during a 
ten years' trial ; nitric acid combined with strychnia ; tan- 
nin, glycerine of tannin, singly and combined with olive 



GONORRHCEA AND ITS SEQUELS. 32 1 

oil and mucilage ; glycerine, combined with carbolic 
acid and tannin ; glycerine and starch ; matico, subse- 
quently stated by Signor Carlo Ambrosoli to be the last 
medicament of the kind we should have recourse to ; 
starch ; tincture of catechu, solution of catechu in syrup 
of tolu ; tincture of rhatany, extract of rhatany ; vinum 
opii, tincture of opium, watery extract of opium, opium 
and glycerine ; decoction of poppies ; acetate of mor- 
phia ; belladonna ; chloroform ; hydrate of chloral ; tinc- 
ture of aloes ; hydrastin ; leptandrin ; red wine ; copaiba, 
volatile oil of copaiba, repeatedly tried in vain at the 
recommendation of previous observers ; honey ; green 
tea ; wine ; ice-cold water, lukewarm water, not known 
to have failed " where the system was adopted at the 
commencement of the disease and followed through- 
out," warm water, recommended by Dr. John O'Rielly 
as curing in from seven to nine days ; earth and water, 
often curing in two or three days, and retention of the 
urine by means of a kind of forceps {pince). Though 
the last can scarcely be considered as an injection it is 
intended to act in the same way." 

" I do not know,'' says Mr. Milton, " what the reader 
thinks of this, but to me it is unsatisfactory in the high- 
est degree. In the first place, it would demand a series 
of careful experiments, prolonged for at least fifty years, 
to examine with anything like accuracy the comparative 
value of the different substances here recommended. 
I say this quite deliberately, for it took me more than 
two years, at a time when I was not overburdened with 
private practice, to satisfy myself even imperfectly as 
to the relative power of three drugs only, namely, the 
sulphate of zinc, acetate of zinc, and the nitrate of 
silver." 

Of his own experience, he says, page 119 ibid.: "I 
have for years employed injections so soon as ever I 
could obtain the patient's consent to let me use them, 
and have never in a single instance had to reget doing 
so." And he says of injections of nitrate of silver: " Of 
ail the substances ever employed for injections this is, 
to my thinking, the best. I have seen a great number 
of injections tried, and have one time or other tried a 



322 GONORRHOEA AND ITS SEQUELS. 

good many myself, but I have never observed any exer- 
cise such a marked control over gonorrhoea as a solution 
of nitrate of silver, properly given, and of the proper 
strength. Yet it is used by comparatively few practi- 
tioners, and it is no uncommon thing to hear surgeons 
say that they have given it up, in consequence of failing 
so often with it, or from its bringing on stricture. The 
latter objection is, I think, already got over. The former 
merits decided attention," but on the following page 
(p. 120) he says that, "its power as a curative agent, 
when employed without the aid of other means, is in 
the general run of cases very limited." 

Mr. Milton's opinion of the value of injections as a 
curative agent in the treatment of gonorrhoea, would 
seem, then, to depend chiefly upon the use of other 
means used at the same time. It is evident, from his 
statement to this effect in the preceding paragraph, that 
he does not consider them a necessity. 

The statistics which Mr. Milton presents, on page 70 
would seem to show that a copaiba diet, in the aver- 
age case, could not be estimated at less than about four 
weeks. On page 68 he gives his opinion that, "per- 
haps, without exception, the most potent and generally 
used of all the internal remedies for gonorrhoea, is 
copaiba, one of the most nauseous drugs ever found out" 
and, further, he says, " it is quite time that men ban- 
ished it from the therapeutics of this complaint;" and 
again, at page 70 ibid., he remarks that, as " no amount 
of experience will enable the surgeon to diagnose at the 
outset those cases in which copaiba will be useful, from 
those in which it will almost certainly fail, it necessarily 
follows that every surgeon who treats all cases with 
copaiba — and there are plenty who do so — must give it in 
many instances where it is sure to be of no service." 
In regard to the dose and mode of giving copaiba, Mr. 
Milton says, page 73 : " Some surgeons give four and 
twenty times as strong a dose as others." As to the best 
time, he quotes Dr. Bumstead,* assaying that, " Copaiba 
can be administered with safety and to much greater ad- 

* Bumstead and Taylor, 4th Ed., page 65. 



GONORRHOEA AND ITS SEQUELS. 323 

vantage in the acute stage of gonorrhoea, or at an early 
period in the stage of decline, than afterwards, and the 
same is true of cubebs." Mr. Milton says: " My own 
experience quite confirms this. ... As to waiting until 
the inflammation is subdued, it is, to the best of my judg- 
ment, simply useless," whereas, Hill and Cooper, page 
513, say, " The good effect of copaiba depends almost en- 
tirely on its being given when the mucous membrane is 
ready for it. If given too early it fails to do good, and 
sometimes does harm." Milton quotes a reviewer in one 
of the recent medical journals as saying, that, "no 
sensible or experienced surgeon would think of giving 
copaiba in the acute stage of gonorrhoea." 



324 GONORRHCEA AND ITS SEQUELS. 



LESSON XXXVIII. 

Previous quotations from authorities given to show essential differences 
of treatment — All claiming equally good results — In all cases where 
short period of cure is claimed the disease probably not gonorrhoea — 
Evidence in proof of this statement — Specifics not essential to the cure 
of gonorrhoea — Simple measures shown to be most efficient — Author's 
experience in treatment of gonorrhoea without specifics — Rarity of ac- 
cidents by this plan — Promptness of recovery — When not successful 
some mechanical difficulty usually present — Contractions of meatus 
urinarius a common cause of prolonging gonorrhoea — Author's plan of 
managing a case of gonorrhoea — Cure by all plans of treatment ex- 
plained — Cases which continue rebellious due to causes independent of 
the gonoirhceal irritant — Specifices and injections valueless to complete 
a cure when stricture is present — Mechanical causes must be appre- 
ciated if the diseased conditions are to be permanently cured. 

I have been thus full, and circumstantial, in laying be- 
fore you the views of recent accepted authorities, in or- 
der that each statement in regard to differences between 
them, could be readily substantiated. To show that 
many medical men have been taught, that specific reme- 
dies were essential to the cure of gonorrhoea, and that 
as many others, did not consider them essential. That 
one party believes, that they are only useful in the early 
stages of the disease, while another party considers 
them comparatively useless in the early stage, and high- 
ly beneficial in the latter stage, and that both parties 
prescribe copaiba largely. 

It has thus also been seen, that injections are essential 
to the cure of gonorrhoea in the opinion of one party, 
while another considers them, at least useless in curing 
the disease, and the source of much unnecessary trouble 
and danger. It has thus also been seen that, while many 
claim great and uniform success in treatment by injec- 
tions of one kind, others find no value in it, while an- 
other kind in other cases has been promptly curative. 
It has also been seen that, where a short period has been 
claimed in the cure of the disease by any method, it has 
been always doubtful if it was a true gonorrhoea. It is 



GONORRHCEA AND ITS SEQUELS. 325 

also easily seen, that authorities are quite agreed, that 
some cases are rebellious to any, and every mode of treat- 
ment, and that the average time for cure, by any means 
at present generally known, is nowhere claimed to be 
less than four weeks. 

It will be interesting, and perhaps instructive, to recall 
the fact, that 60 cases are cited where a cure of gonor- 
rhoea was effected by extensive blistering of the thighs, 
and that the average duration of each case was from 
five to seven days, and that in Mr. Milton's sixteen cases, 
treated by injections and purgatives and copaiba, three 
were cured after an average duration of sixty-three days, 
while the remaining thirteen cases were left with a 
gleety discharge. 

It is also a significant fact that all the authorities 
quoted, lay great stress on the necessity of rest and local 
antiphlogistic measures, and attention to diet and con- 
dition of the urine. These are the only practical points, 
on which all are in perfect accord : on all other points 
they differ diametrically. It is also a significant fact 
that, notwithstanding such wide differences on matters 
of great practical moment, there is a curious coincidence 
in the duration of the disease by all the different meth- 
ods. It is also a fact equally curious that if we offset 
the differences between authorities, and treat cases of 
gonorrhoea by the means upon which all are agreed, viz., 
rest, sexual, hygienic, local and antiphlogistic measures, 
attention to diet and condition of urine, the average 
duration of the disease, is quite as good as when specifics 
and injections are used. This statement I make, after 
an experience with such method of at least ten years. 
By this plan, in the matter of rest alone, the results of 
absolute rest may be inferred from alleged effect of the 
six-inch blisters to the thighs of patients of Mr. Chal- 
mers Miles (page ), where the average duration of the 
disease was claimed to be not over seven days. It is 
certain, however, that but few of these cases were true 
gonorrhoea. In the matter of sexual hygiene, diet, con- 
dition of urine, etc., it is simply common sense to accept 
these as aids to cure. In the matter of local antiphlogis- 
tics, Mr. Milton's statement in regard to the effect of hot 



326 GONORRHCEA AND ITS SEQUELS. 

water in cases of gonorrhoea, is quoted by Bumstead with 
hearty endorsement, thus : * " The only direct applica- 
tion which I can safely say has never disappointed me, 
which is at once safe, simple and useful, is that of very 
hot water to the penis ; but to obtain the really good 
effect it offers the water must be hot, not lukewarm. In 
fact, we seldom see so much good ensue, as when it is 
carried to the extent of producing some excoriation and 
faintness ; thus applied, and especially in the early stages 
of the disease, the weight felt about the testicles soon disap- 
pears. The pain on making water and using injections is 
soothed and the prepuce and glans rapidly regain a more 
normal temperature and color." 

With such a remedy even copaiba in large doses 
might be used with impunity. As Milton remarks, 
among its other benefits, " even pain on making water 
and {even) using injections is soothed." It was the trial of 
Mr. Milton's hot water cure, as above cited, that led me 
in the first instance to distrust the value of specifics and 
injections. Fully ten years ago, cases occurred in my 
practice where neither injections nor copaiba mixtures 
were tolerated, and to my great surprise I very soon 
found that such cases got well as promptly as those 
where copaiba and injections were used, and that where 
the discharge lasted more than a month or six weeks, 
some mechanical obstacle to recovery, such as a con- 
tracted urethral orifice or a stricture more or less salient, 
was found in the deeper portion of the canal. For the first 
three or four years, I treated vigorously in this manner, 
only those cases in which the copaiba, cubebs, etc., were 
not well borne, but I came to appreciate the fact that 
gonorrhoeas of recent date, and especially first gonor- 
rhoeas, were more promptly cured, than by the old meth- 
od, and that there were no cases complicated by epid- 
idymitis among them, and that all the annoyances, 
errors and troubles, arising from the use of injections 
were effectively avoided. 

My plan, based originally upon that of Mr. Milton's 
previously quoted, was as follows: ist. To explain to 

*Bumstead and Taylor, 4th Ed., 1879. Page 54. 



GONORRHOEA AND ITS SEQUELAE. 327 

the patient the inefficiency of the popular remedies and 
the damage likely to be done to the digestive functions, 
etc., by taking them, and explaining the nauseous char- 
acter of the medicines, popularly supposed to be essen- 
tial to the cure of the disease. This latter argument 
was often useless, from the fact, that a very large 
proportion of cases, are inclined to look upon their 
trouble, as a judgment upon them for their folly, and 
often seem to take pleasure in self-inflicted penance 
through their medicines, frequently saying : " Make 
the dose as nasty as you choose — the nastier the better; 
I deserve it all," and more to that effect. In point of 
fact, I believe that on no other ground can the long suf- 
fering of gonorrhceal patients, their, philosophical en- 
durance of the painful and disgusting injections, and the 
pints of copaiba which they are induced to swallow, be 
explained. The mystery of an annual consumption of 
the 151,000 pounds of that most nauseous, misnamed 
anti-blenorrhagic, copaiba, by the British public, can in no 
other way find solution, and I believe I am not far wrong, 
when I venture to state that an equal estimate for the 
United States, is taken, not for any real value experi- 
enced, but because of its popular reputation, based upon 
negative evidence, and upheld by the druggists and the 
unsupported traditions of the medical profession. 

2nd. To secure complete personal cleanliness. Espe- 
cial care to prevent any possible transference of the gon- 
orrhceal secretion to any other mucous membrane, es- 
pecially of the eye, the rectum, the nares ; and to insist 
upon rest, as complete as practicable on the back, if pos- 
sible, until the inflammatory stage begins to decline, 

3d. Frequent soakings of the penis in water as hot as 
can be borne. Urination always to be performed with 
the penis immersed in the hot water, and for general 
cleanliness, to take other occasional warm and tepid 
baths. 

4th. To put the patient on a milk diet, as the highest 
type of suitable nutriment, and to use all practicable 
means by which the urine may be freed from its irritating 
properties. Alkalies and diluents, in the form of Vichy 
water (Celestins'), and bicarbonate of potash ten grains 



328 GONORRHCEA AND ITS SEQUELS. 

dissolved in a tumbler of water, or flaxseed tea, or in- 
fusion of dog-grass (Triticum repens rad.), adding twenty 
grains of bromide of potassa if great pain or irritation 
is present, and drinking freely to the extent of a tumb- 
lerful every four or five hours, and other demulcents, 
or diluents that may be found more convenient or 
agreeable in any given case. Flavoring any suitable 
drink freely with the tincture of gaultheria if agreeable. 

5th. To secure perfect freedom from all sexual con- 
tact, or from any association, or conversation, or read- 
ing material which may have a tendency to excite ve- 
nereal thoughts or desires. 

To continue this plan of treatment, as fully as may 
be practicable, entirely free from any so-called gonor- 
rhceal specifics or injections, until the complete ces- 
sation of the discharge, or until the sixth week from the 
commencement of the disease. Should any discharge 
or any urethral irritation be present, after this time, it 
would, in my opinion, be proper to assume that some 
mechanical obstacle to the complete cure of the disease, 
was present at some point in the urethra. In such case 
an examination of the urethra, with the view of ascer- 
taining its exact locality and degree, should be made. 
Congenital contraction of the urethral orifice stands first 
among the probable causes of such continuance. The 
case is now no longer one of gonorrhoea, and must be 
considered as one of gleet, dependent solely on mechani- 
cal causes for its continuance. These causes, and the 
proper treatment necessary for their removal, will be 
considered under the head of Gleet. 

It will be interesting at this point to recallsome appar- 
ently anomalous features in the history and treatment 
of gonorrhoea, which figure prominently in the statistical 
records of gonorrhoea as previously presented. Under 
every form of treatment — expectant, abortive, by specif- 
ics, by injections, by blistering, by carthartics, by aperi- 
ents, by diluents and diuretics and alkalies, some cases 
get well in a few days, while others are apparently rebelli- 
ous to any and all treatment, singly or in combination. 
The explanation to me is simple. All cases which, un- 
der any treatment, or no treatment, get well in a few 



GONORRHOEA AND ITS SEQUELAE. 329 

days are not true gonorrhoea. All cases which con- 
tinue beyond six weeks owe that continuance either to 
sexual excitements, to digestive disturbance, causing 
acidity of the urine, or to localized points of irritation, 
chiefly contractions of the urethral calibre at some 
point. In such cases, specific medicines and injections, 
of whatever nature are valueless. The cause must be 
appreciated, and treated independently of any precon- 
ceived notions of the specific character of the disease. 



330 GONORRHOEA AND ITS SEQUELS. 



LESSON XXXIX. 

Reasons why injections in the inflammatory stage of gonorrhoea are con- 
demned — Dangers inseparable from their use — Nature of accidents due 
to their use — Use of injections in the chronic forms of gonorrhoea — 
Conditions which warrant their use — Mode of ascertaining such con- 
ditions — Explanation of their curative action in certain cases — Method 
of management — Illustrative formula — Manner of administering in- 
jections in suitable cases — Gleet — Nature of — Physiological conditions 
producing it — Manner of its development — Character of urethral in- 
flammations differ in degree and not in nature — Products the same 
from whatever cause — All susceptible of developing a contagious ele- 
ment — Whether arising from mechanical or from gonorrhceal causes. 

Condemning as I do all injections during the inflam- 
matory stage of gonorrhoea, I have not considered 
their possible utility in the stage of decline, simply be- 
cause I do not consider them an essential feature in any 
case. Furthermore, in the indiscriminate and perfunc- 
tory way in which they are usually administered, I think 
that even in the non-inflammatory stage of gonorrhoea 
they are productive of more harm than good. I have 
seen quite a number of cases of acute prostatic inflam- 
mation (occasionally going on to the production of ab- 
scess), which I have been quite satisfied were caused by 
driving an injection of ordinary strength, into the deep- 
er parts of the urethra. To the same cause I have also 
attributed the accession of the epididymitis, which I 
have frequently met in cases of chronic urethral dis- 
charge while injections were in use. I feel satisfied 
that pus from the anterior urethra, is in this way, carried 
to the deeper and healthy portions of the canal, with the 
effect of establishing a new process of contagion in that 
region. Drs. Bumstead and Taylor (p. 57), are inclined 
to deny the possibility of such an accident, because the 
patient is directed to urinate before injecting, claiming 
that thus, the pus is all washed out of the canal and none 
is left to be projected back by the injection. It seems 
to me more probable, that with the fullest urination 
enough might remain in the crypts and follicles which 



GONORRHCEA AND ITS SEQUELS. 33 1 

look forward, to furnish a dangerous element, on a 
washing of the urethra backward with the injection. 
Besides this, the great majority of patients, no matter 
how thoroughly instructed, occasionally omit the pre- 
caution. There is a great difference in the receptive 
power of patients in the matter of injections : With some 
they are introduced with great difficulty beyond the 
nib of the syringe used ; in others the fluid passes, 
with slight force, well into the deeper urethra, and in 
occasional subjects even into the bladder.* My chief 
objection, however, to the use of injections is, that how- 
ever well administered, and judicious, they are seldom 
required, except when the discharge is kept up by me- 
chanical influences, and that, in such case, the true 
cause of its continuance, is masked by the astringent 
effect of the injection, often affecting an apparent cure, 
only to disappoint and vex the physician, and his patient, 
by repeated recurrences, as soon as the temporary effect 
of the injection has passed off. I would, therefore, 
while admitting that, in the absence of mechanical ob- 
structions, the discharge may be lessened by use of 
astringent injections of various kinds, prefer, for the 
reasons above cited, to defer their employment until 
their necessity was indicated, after the fourth week, by 
the continuance of the discharge and the failure to de- 
tect any mechanical causes for its continuance. When, 
after a longer or shorter time, the acute symptoms of an 
attack of gonorrhoea have subsided, and there remains 
simply a muco-purulent, painless discharge, examination 
should be carefully instituted, with the view of ascer- 
taining the exact point to which the disease has extend- 
ed, and, as nearly as possible, the pathological condition 

* A very general impression exists in the profession that fluids are with 
difficulty injected into the deeper parts of the urethra by an ordinary 
syringe, and that to force them into the bladder, by that means, is a phys- 
ical impossibility. The positive statements to that effect by various au- 
thors (Acton, Milton, etc.) would tend to confirm such a belief. Within 
the past two years I have had three patients who were able to inject their 
respective bladders by means of an ordinary Davidson's syringe, one of 
them throwing in a pint of water, in my presence, then emptying the vis- 
cus — refilling and discharging it three times in succession. I am, there- 
fore, convinced that it is judicious to limit the distance we desire to med- 
icate, by pressure on the canal at a given point. 



332 GONORRHOEA AND ITS SEQUELAE. 

upon which the continuance of the discharge depends. 
This may be done, in a rough way, by pressing the walls 
of the urethra together and squeezing out the discharge 
from the meatus, making the pressure farther and far- 
ther back, until no more fluid can be made to exude. In 
the absence of any tenderness, or uneasiness, beyond the 
point so examined, you may conclude that the disease 
has not extended beyond that limit. If, in addition, a 
fair-sized bulbous bougie fails to detect any special 
points of tenderness, it may be concluded that the diffi- 
culty is dependent upon the first of the causes mention- 
ed, viz., a want of recuperative power in the epithelial 
structure, and that there is sufficient of the gonorrhceal 
influence, to keep up an exaggerated desquamative ac- 
tion, though not sufficient to excite acute inflammation. 
The additional fact, that the membrane is kept constant- 
ly bathed in fluid, also retards the return to a normal 
condition, by diminishing the cohesive power of the su- 
perficial cell growths, The indications for treatment 
then are, to apply such local means as are most likely to 
diminish the excess of fluid, and to stimulate the mem- 
brane to a more complete performance of its functions. 
Solutions of the salts of zinc, lead, and iron, combining 
astringent and stimulating properties in various degrees, 
are found well calculated to meet this double require- 
ment. Vegetable tonics and astringents are also of value. 
The more thoroughly the epithelial products in the dis- 
charge are degenerated, the more stimulating and as- 
tringent is the application required ; so that, when the 
discharge is thoroughly purulent, the more stimulant 
salts, as the chloride, sulphate, or acetate of zinc, etc., 
will be found most beneficial ; the more it approaches 
the mucous character, the more simply astringent should 
be the application. Under all circumstances, where a 
simple atonic condition perpetuates the discharge, no 
solution of any sort should be used of a strength suffi- 
cient to produce a caustic effect. Stimulation alone is 
required, such as results from solutions of the sulphate 
of zinc, or the acetate of lead, alone or in combination, 
and of a strength varying from one to three grains to 
the ounce of distilled water. When the discharge is not 



GONORRHCEA AND ITS SEQUELS. 333 

wholly without pain, I am accustomed to add two or 
three grains of the extract of belladonna to the ounce. 
When the discharge is small in quantity and chiefly mu- 
cous, the acetate of lead, grains one to three ; the per- 
sulphate of iron, grains three to five ; tannic acid, grains 
five to ten, are often promptly efficacious. The power of 
phenol (the so-called carbolic acid) to modify and arrest 
suppurative action, wherever located, is now general- 
ly admitted. A solution of from one to three grains 
to the ounce of distilled water is often of value. A bland 
solid material like the oxide of zinc thoroughly pulver- 
ized may be added to any injection with occasional ad- 
vantage, especially if the urethra is still sensitive — thus : 

3 . Zinci Oxidi 3 ss. 

Zinci Acetate gr. viii. 

Aqua Calcis § iv. 

M. 
Adding aqua calcis, which seems, in some cases, to in- 
crease the efficiency of the injection. Whatever form of 
syringe is used, the chief point of importance is to se- 
cure the limitation of the injection to the diseased por- 
tion of the canal alone. Thus, taking any one of the 
ordinary syringes in use, slip on its extremity the end 
of a soft velvet-eyed catheter (Tieman's or its equiva- 
lent), of a length proportioned to the distance required 
to reach the furthest point of diseased membrane, and 
of a size not more than 20 to 24. After urination, 
fill the syringe, introduce, well oiled, slowly, to desired 
point, discharge it gently and completely, and retain 
from half a minute to two or three ; repeat three or four 
times a day, unless this procedure causes irritation, 
then it, and all other applications by injection, may be 
judiciously withheld, and the case relegated to the list 
of troubles known under the title of gleet. 

The secretion of the urethral mucous membrane 
serves as a protector, and lubricant, for the preserva- 
tion of this membrane from contact with the irritating 
urinary fluid. It is made up of germinal granules — 
particles of bioplasm (Beale), which rise up through the 
interstices of the sub-mucous cellular tissue,* are trans- 

* Rindfieisch, Pathological Histology, Am. Ed. pp. 43, 99 et seq. 



334 GONORRHCEA AND ITS SEQUELAE. 

uded through the basement mucous membrane, and 
become organized as the protective and lubricative 
epithelial cells of the urethral mucous membrane ; and 
where the conditions of its evolution are in every re- 
spect perfect, in quantity just sufficient for the lubrica- 
tion and protection of this structure. This is never 
sufficient to be perceptible to the naked eye, except as a 
moist glazing of the surface. Any excess is always the 
result of an abnormal stimulation of the natural pro- 
cesses, except in a single instance, purely physiological, 
when it proceeds from erotic excitement, and appears 
at the urethral orifice as a transparent mucous exuda- 
tion, which passes off with a cessation of the nervous 
impression which provoked it. The causes which un- 
duly increase the secretion of this membrane (and in 
speaking of the urethral mucous membrane, I include 
the glands, crypts, and follicles, made up of its local re- 
duplications), are to be divided into two classes: — first, 
active inflammation set up by contagion, or clap ; and 
second, mechanical injury or obstruction, such as ure- 
thritis, from lodgment of calculus, or injuries caused 
by irritant injections, or instrumental violence, or from 
urethral stricture. 

The first effect of an approaching inflammation of 
mucous membrane is an increase in the natural secretion. 
The mucous cells are hurried along, through their dif- 
ferent stages of development, and, as the amount of se- 
cretion increases, it is less and less perfectly elaborated. 
The germinal material is drawn to the surface with in- 
creasing rapidity, until cells, which, in health, pass 
through a gradual development, from the germinal 
granule to the fully formed epithelial scale, now appear 
as a mass of emasculated corpuscles — pus cells, which 
constitute what we are accustomed to designate as a 
purulent discharge. 

The inflammation is thus characterized, during its con- 
tinuance, whether arising from contagion or from me- 
chanical or traumatic causes. The character of inflam- 
mation in the urethral mucous membrane, va"'js in 
degree, rather than in kind. Its products are, to all ap- 
pearance, similar, whether the result of gonorrhceal 



GONORRHCEA AND ITS SEQUELS. 335 

contagion, or from injury caused through instrumental 
or mechanical interference alone. The duration of the 
inflammation varies, as the cause is more or less vicious 
in its onset, or more or less persistent in its influence. 
An inflammation set up by a gonorrhceal contact will 
continue, in spite of the most efficient and judicious 
treatment, for several weeks, while the inflammation 
caused by the forcible introduction of a sound through 
a narrow meatus urinarius, may subside in a few days, 
and yet circumstances, wholly unconnected with contagion, 
may elevate this latter discharge, from a purely trau- 
matic inflammatory product, so that it may communi- 
cate a disease, to a perfectly healthy individual, in no 
way distinguishable from a gonorrheal inflammation. 



336 GONORRHOEA AND ITS SEQUELS. 

LESSON XL. 

GLEET. 

Pus from a gonorrhoea contagious in the outset — Pus from simple ure- 
thritis gradually elevated to the point of contagiousness —This through 
various well-recognized causes — Importance of this positive in prac- 
tice, also in a medico-legal point of view — Definition of gleet — Usually- 
considered a chronic gonorrhoea — Evidences that it is often produced 
by purely mechanical conditions — Mr. Dick's views dissented from — 
Urethral stricture the most common cause of gleet — Urethral sinuses 
a possible cause — Dick, Le Roy d'Eliolles and Sir Henry Thompson 
in proof of stricture as a cause of gleet — Bumstead and Taylor, also 
Van Buren and Keyes, supporting this view — Necessity of examining 
for stricture in all cases of gleet — Ordinary sounds valueless for de- 
termining the presence of stricture — Value of the urethrometer as a 
means of diagnosis — Description of the urethrometer. 

An inflammation, set up by contact with pus, from an 
acknowledged gonorrhoea, at once partakes of the vi- 
cious, contagious character of the inflammatory pro- 
ducts from which it was derived. A simple urethritis 
may continue simple, and recovery take place within a 
short period, or it may be aggravated by various influ- 
ences, such as vinous or sexual excess, contact with 
uterine or vaginal secretions, prolonged physical exer- 
cise, or from simple mechanical irritation, in a strumous 
or gouty diathesis, until it shall have acquired the prop- 
erty of contagiousness. Arrived at that point, urethri- 
tis of non-venereal origin does not differ in any way 
from that which has been originally acquired by conta- 
gion. The contagium, or contagious element present in 
gonorrhceal inflammation, would seem to be due to an 
acquired viciousness, from the fact that this contagium 
may be developed, or induced, in simple urethritis, by 
the various causes above enumerated, independently of 
contact with the gonorrhceal secretion. This position, 
most important in practice, as well as in a medico-legal 
point of view, is capable of substantiation by eminent 
authority, and besides, I have personal knowledge of 
its truth, from a number of carefully observed and re- 



GONORRHOEA AND ITS SEQUELS. 337 

corded cases. The active stage of an inflammation of 
the urethral mucous membrane is called an urethritis, 
when resulting from causes independent of venereal 
contact, and when referable to a contagious origin, it is 
termed a gonorrhoea. Its duration in the great majority 
of cases may be set down as four or five weeks. In 
the cases where complete recovery does not take place 
within this time, there is usually a subsidence of the 
more acute symptoms, and the case is then character- 
ized by a painless or nearly painless discharge, more or 
less profuse, and more or less purulent, which persists, 
in spite of the most earnest and judicious treatment by 
internal and local remedies, for weeks, perhaps months 
— often years. At times reduced to a mere secretion, 
which sticks the lips of the meatus together, when, 
upon a slight indiscretion in diet, a little sexual or vinous 
indulgence, within a few hours it may return as a free 
and possibly painful discharge. This chronic form of 
urethritis, which has, from time immemorial, afflicted 
humanity, and which has probably been the source of 
more trouble, to patients and surgeons, than any other 
known difficulty, is familiarly known as GLEET. 

It is usually considered either as a sort of chronic 
gonorrhoea, and treated on the same general princi- 
ples (by internal remedies and local injections), or is 
looked upon as the result of a debilitation of the ure- 
thral mucous membrane, but having no specific or con- 
tagious property associated with it, and is treated by 
specific and local means, with the addition of some con- 
stitutional remedies addressed to the condition or dia- 
thesis upon which the continuance of the difficulty is 
supposed to depend. Now, if it can be established that 
gleet is the result of a mechanical condition, that it may 
be produced, without the previous occurrence of a 
gonorrhoea, by a simple obstruction to the free dis- 
charge of urine through the urethra, and that this ob- 
struction may occur as a result of any inflammation or 
injury which shall implicate the sub- mucous urethral 
tissues, it will then be clear that no treatment, which is 
not based upon the detection and removal of the me- 



338 GONORRHOEA AND ITS SEQUELS. 

chanical difficulty, can be more than palliative. And if 
it can be shown, that the detection oi contraction is pos- 
sible in all cases of gleet, and that its removal is certain 
to result in the cure of the gleet, the proof of the non- 
specific character of gleet may be considered estab- 
lished. 

Mr. Henry Dick, of London, whose brochure on the 
" Pathology and Treatment of Gleet" f is in my opin- 
ion the most valuable contribution to the literature of 
this subject in any language, says, " Gleet is always the 
consequence of a clap. I have never seen it idiopathi- 
cally appear without clap, except in cases of disease of 
the prostate gland or the bladder, I would not say 
that idiopathic gleet never exists, but I have never seen 
it." This statement conveys the impression which was 
formerly accepted by the profession in regard to the 
cause of gleet, and has been a source of frequent error 
both in diagnosis and treatment. 

Acute urethritis, from whatever cause, and it acknowl- 
edges many, may be stated as a self-limited disease. A 
disease which, under various methods of treatment by 
internal remedies, such as copaiba, cubebs, sandal-oil, 
etc., by alkalies and diuretics of various kinds, by local 
injections, such as sulphate of copper, sulphate of zinc, 
acetate of copper, acetate of zinc, acetate of lead, nitrate 
of silver, any and all of the mineral salts or vegetable as- 
tringents, preparations of carbolic acid, liquid glass (sili- 
cate of soda), fuller's earth, or any one of the thousand 
injections which have been used and lauded for their 
curative influence on acute urethritis — or by no treat- 
ment at all — has a tendency to get well within a limited 
time, and that time may be stated to be about four weeks. 
Dr. Bumstead % formulates the experience of the profes- 
sion, past and present, in the statement that the average 
duration of the disease is " three or four weeks!' " Greater 
success on the average" says Dr. Bumstead, " is probably 
not attainable by any means with which we are at present ac- 



j Published by Bailliere Bros., in 1858. 

\ Bumstead on Venereal Diseases, Phil., 1870, p. 92. 



GONORRHOEA AND ITS SEQUELAE. 339 

quainted." I have met quite a number of well authenti- 
cated cases, where there was a history of a severe gon- 
orrhoea with inflammatory complications, which recov- 
ered within this time, under the use of baths alone ; 
others, where homoeopathic treatment was resorted to ; 
and others again, where no treatment at all was had, and 
where recovery came within the four weeks. Now, 
while I am sure that a variety of remedies, local and 
general, may, when judiciously employed, enable the 
patient to pass through the disease with much more 
comfort, and less danger of subsequent trouble, than 
without treatment, yet I am quite prepared to state as 
my opinion, based upon a large personal experience in 
the treatment of this disease, by the most approved 
methods, that it is a self-limited disease in its acute form, 
and, when it lasts longer than four weeks, or when ap- 
parent recovery takes place, and the discharge breaks 
out afresh without new exposure, that there is a compli- 
cation present, either the result of the current inflamma- 
tory trouble, or of some inflammation antecedent to the 
attack, which causes the continuance of the trouble, 
and which must be appreciated and removed before 
any permanent cure can be had. This complication is 
Urethral Stricture — Stricture in the sense of an 
abnormal contraction of the urethral calibre, at some 
point at or between the meatus urinarius and the bulbo- 
membranous junction ; and I will furthermore state it 
as my conviction, that the continuance of the inflamma- 
tory trouble (and whenever there is an urethral dis- 
charge, there is incontestably, more or less inflammatory 
trouble) is due to the irritation kept up by the arrest, 
more or less complete, of the stream of urine at the 
point of Stricture, and by the imperfect emptying of 
the urethra after urination. Chronic gonorrhoea — Gleet — 
also variously designated as prostatic, gouty, scrofulous, 
is dependent, as a rule, on abnormal contractions of the 
urethral canal. The only exception that I recognize 
(aside from the presence of polypoid, or warty growths 
in the urethra) is the engagement of urethral sinuses 
(as the lacuna magna, or some one of those occasionally 
met near the meatus, possibly deeper down), and these 



340 G0N0RRHCEA AND ITS SEQUELAE. 

I have never found engaged, unless more or less co- 
arctation at an anterior point was also present. Chronic 
urethral discharge means Stricture. I am quite aware 
that well-defined Stricture may be present, without a 
palpable discharge, but there is always to be found evi- 
dence of a certain degree of irritation present in all such 
cases, although there may be no appreciable discharge. 
When, however, there is discharge, there will, in every 
case, be found, if the examination is efficiently made, a 
well-defined and unmistakable point of Stricture. 

The dependence of continued inflammation in gon- 
orrhoea, and of the continuance of chronic urethral dis- 
charge, upon the presence of Stricture, is no new dis- 
covery. All the recent approved authorities recognize 
it. Dick was the first, so far as I know, to insist upon a 
thorough examination of the urethra for obstruction in 
every case of gleet, and his instructions for the exami- 
nation of the urethra with the bulbous bougie of Le 
Roy d'Eliolles are minute and complete. Sir Henry 
Thompson says in his work on Stricture of the Urethra, 
page 90 : "I have known instances in w T hich this symp- 
tom (gleet) has been so prominent that the patient has 
been treated for a gonorrhoea, during a period of 
many weeks, without suspicion arising that a Strict- 
ure existed, which was its sole cause ; the subsequent 
recognition of the contraction and its cure having 
been attended with the complete cessation of the dis- 
charge." 

Dr. Bumstead (Bumstead on Venereal Diseases, 1870, 
p. 93,) says : " It is not impossible that there is stricture 
of the urethra, which is the most frequent cause of the con- 
tinuance of a gleety discharge following an attack of gonor- 
rhoea. 

Van Buren and Keyes, p. 71, say : " The most common 
of all causes for continued gleet is stricture, already present 
or forming" and yet, in spite of the unmistakably pointed 
and positive statement of these, and other valued au- 
thorities, the usual treatment of chronic gonorrhoea and 
of gleet at the present day is by nostrums, sandal oil, 
copaiba, urethral injections in multiplicity, and the use 
of medicated bougies and sounds. And why ? It is 



GONORRHOEA AND ITS SEQUELS. 34I 

not that urethral stricture is doubted as a possible 
factor in the case ; it is not that this is unrecognized as 
the most probable cause of the difficulty ; but because 
the examination of the diseased urethra is conducted 
with imperfect instruments, and that, as a consequence, 
no exhaustive examination of the canal is made. The 
least contraction at any point in the urethral canal has been 
demonstrated as capable of causing the indefinite continu- 
ance of an urethral discharge and even of establishing it, 
de novo, without venereal contact* If this is the fact, 
then some means for the detection of the least contrac- 
tion of the urethral canal must be used in order to 
ascertain the presence or absence of stricture. To this 
end, the first step must be to ascertain the normal 
urethral calibre in the presenting case. It has been 
proved that every urethra is an individuality, and that 
no average standard is of use in examining a given 
urethra. The establishment of the normal calibre is the 
first step towards ascertaining whether or no there be 
any coarctations in its course. This can only be 
accomplished by actual measurement by means of an 
urethra-meter. The proposition is a purely mechanical 
one. Given a tube, urethral or otherwise, in which it 
is desirable to ascertain whether or not there exists a 
contraction of its calibre at any point, the first question 
to settle is the size of the tube ; this effected, the deter- 
mination of any variations becomes easy ; without it, 
impossible. The bulbous bougee was relied upon by 
Le Roy d'Etoilles, Dick, and others, many years since, 
and it has been growing in favor very slowly but 
surely, so that now it is an indispensable instrument in 
urethral examination for stricture. Explorations with 
an ordinary sound, catheter, or straight bougie, are 
practically valueless in determining the size, locality, 
and number of strictures in a given case. The pres- 
ence of a contracted meatus (a very common compli- 
cation, as a result of infantile balanitis or gonorrhceal 
inflammation) makes the detection of any deeper strict- 
ure, if of greater calibre, quite impossible. The sudden 

* Page 20. 



342 



GONORRHOEA AND ITS SEQUELS. 



release of a bulbous sound or bougie, of a size which, 
by firm but gentle pressure, may be made 
to pass through the meatus, indicates, as it 
slips into the fossa navicularis, that contrac- 
tion is present at that point; and the re- 
lief of the contraction becomes a necessity 
before the deeper canal can be efficiently ex- 
plored, or the normal calibre of the urethra 
be estimated. It is here that the value of the 
urethra-meter in the diagnosis of strictures 
becomes evident. This should be introduced 
through the contracted meatus (when this is 
not below 12 F.), and down to the bulbo-mem- 
branous junction. At this point the bulbous 
portion of the instrument is to be expanded, 
by means of the screw at the handle, until a 
feeling of fulness is experienced, when, if there 
is no stricture at the point of trial, the pointer 
on the dial plate will indicate, with sufficient 
certainty, the normal calibre of the urethra 
under examination. Now, drawing the in- 
strument slowly out, if stricture is present, 
the bulb will be arrested at that exact point. 
The screw is then turned, diminishing the 
size of the bulb, until it slips through the 
coarctation, when a glance at the dial will 
show the calibre of the stricture. This sub- 
tracted from the figures indicating the normal 
calibre, will give the precise value of the con- 
traction. The remainder of the canal, exam- 
ined in the same way, brings the bulb finally 
to the meatus, where, in the same manner, the 
greater or less degree of deviation from the 
normal size will be shown. Sir Henry Thomp- 
son* as late as 1882, still claims that all that is 
necessary for diagnosis of stricture is a slight- 
ly curved, blunt, flexible bougie. Thus he 
'hra- says : " Take a flexible gum elastic bougie, 
slightly curved toward the point, with a blunt 
(since a tapering point will not mark distinctly 




end 



" Diseases of the Urinary Organs." London, 6th ed. P. 8. 



GONORRHCEA AND ITS SEQUELS. 343 

the site of stricture) not larger as a rule than 10 or 1 1 
of our scale (20 or 21 of the French) and pass it very 
gently and slowly into the bladder. If it goes easily, 
above all if it is withdrawn without being held, and 
slides out with perfect facility, take my word for it, he 
has no stricture and quoad obstruction, wants no use of 
instruments whatever." 




Sir Henry Thompson's Blunt-ended Bougie used for Diagnosis of Stricture. 

A careful examination of over a thousand urethras by 
means of the urethra-metre, warrants me in stating that 
the average calibre of the meatus urinarius is not less 
than 24 of the French scale or 12 of the English, and 
that the average calibre of the male urethra is not less 
than 32. With such facts as a basis of statement, it is 
not too much to claim that Sir Henry Thompson's plan 
of examination is wholly inefficient for practical pur- 
poses, and would, if accepted, inevitably lead to errors 
in diagnosis and treatment. In my work on stricture 
of the male urethra (p. 70, et seq.), the foregoing resume 
of Sir Henry Thompson's mode of ascertaining the 
presence or absence of stricture in a grave case was 
quoted, and the reasons for disputing its value were 
given at some length. I omitted to state that metallic 
bulbous bougies had been previously in use by him, not 
from any desire to deprive him of the credit of famil- 
iarity with the use of those valuable instruments, but 
because he stated distinctly that the blunt-ended bougie 
was sufficient for all practical purposes, and that with 
later experience he had practically given up their use. 
In a private conversation with Sir Henry, during the 
meeting of the late International Medical Congress in 
London in 1881, he claimed that this omission did him 
great injustice. I therefore take this earliest favorable 
opportunity publicly to state, as I then agreed to do, 
that he has commended the use of the metallic bulbous 
bougies, and was once in the habit of defining the local- 



344 GONORRHCEA AND ITS SEQUELS. 

ity of strictures with it. But, as he says, in his last 
edition, 1882,* with his increased experience he no 
longer finds it of service (p. 39). It will be seen that 
the injustice of my omission was not very great. Sir 



Sir Henry Thompson's Metallic Bulbous Bougie. 

Henry speaks in its praise, however, on p. 39 of his 
fifth edition, 1879 ( an d also in the sixth, 1882, p. 20), 
thus : " No other material slides so easily and smoothly 
through the urethra, so that to employ one which passes 
roughly or distends unnecessarily, is to pay too high a 
price for the small amount of information"^ may con- 
vey." I agree most heartily and unreservedly with the 
view of Sir Henry that an instrument " which passes 
roughly or distends unnecessarily" is to be condemned. 
The metallic bulbous sound, however, if properly con- 
structed as in the appended cut and judiciously used, 
is absolutely free from both these objections. Such a sized 
instrument only should be used as will pass without un- 
necessary distension of the urethral tissues. The size 
must be adapted to the size of the urethral orifice in 
any given case, just enough larger to test whether or 
not a contraction exists at this point. It may then be 
passed gently along until arrested at some deeper con- 
traction, and then smaller and smaller sizes should be 
introduced until one is reached that, while easily yet 
snugly slipping through, is held on its return by the 
contraction. Deeper contractions must be treated in 
precisely the same way. The forcible use of such in- 
struments is never necessary and never should be so used. 
Their size must always depend upon the size of the ure- 
thral orifice, which, as has been determined beyond the 
possibility of question, varies in different cases from 



* "Clinical Lectures on the Genito-Urinary Organs," sixth edition, 
p. 20. 



GONORRHOEA AND ITS SEQUELS. 345 

eight or nine millimetres in circumference (when abnor- 
mal contractions are present) up to thirty-eight or forty 
millimetres circumference. Consequently sizes from 
eight to forty, increasing by one millimetre in circum- 
ference, are absolutely necessary in order to enable the 
surgeon to explore all presenting urethra without dan- 
ger of overlooking stricture from lack of suitable means 
to discover it. The sizes are thus numerous in order 
to prevent the inducement to use undue force in the ex- 
amination. The continuance of a gleet is not unfrequently 
due to contractions of small amount, even two or three 
millimetres circumference. On this account it has be- 
come necessary to be prepared to define contractions 
which in the absence of persistent gleet would not call 
for interference. It is only after exhausting all other 
measures, and the gleet still persisting, that attention 
to strictures of so small moment, comparatively, calls 
for consideration. In such cases it is hardly necessary 
to say that any other than bulbous instruments used for 
purposes of diagnosis (the only purpose to which they 
should ever be put) would be wholly inefficient. 

The urethrometer may, it is true, be made available 
for the diagnosis of well-marked contractions in many 
cases. With this we have the great advantage of in- 
troducing it closed to the bulbo-membranous junction, 
and examining the canal from behind forwards, thus 
avoiding the possible discomfort in sensitive urethras of 
introduction of bulbs at full size. But on account of its 
oval shape it is inefficient for accurate diagnosis in cases 
of slight contraction. Here the acorn -shaped bulb 
always defines with certainty. It will be observed that 
another advantage pertains to the use of the urethrom- 
eter, viz., that of enabling the surgeon to examine the 
urethra in the presence of a contracted urethral orifice. 



346 GONORRHOEA AND ITS SEQUELS. 



LESSON XLL 

Henle on the size of the meatus urinarius — Errors of previous observers 
— Meatus urinarius no guide to the urethral calibre — Relation of the 
size of the meatus to the circumference of the flaccid penis — Strict- 
ure long recognized as a cause of gleet — Imperfect means former- 
ly in use for examining the urethra for stricture — Use of the endo- 
scope not efficient in discovering the real cause of gleet — Case in illus- 
tration — Gleet as a rule dependent upon stricture — Efficient exploration 
of the urethra always capable of discovering and locating stricture of 
the urethra — Complete division of stricture results as a rule in the cure 
of gleet — Degrees of gleet — Description of — Explanation of the mode 
of its production — Treatment by bougies, without exact knowledge of 
locality of stricture, empirical — Temporary results of such treatment 
— Complete division of stricture and suitable after-treatment the only 
plan through which gleet may be permanently cured. 

Henle* has demonstrated the meatus urinarius to 
be of uniform size with the fossa navicularis, and thus 
from an anatomical stand-point, has demolished the 
error which has been disseminated by so many authori- 
ties, and which has achieved so much fictitious impor- 
tance as a guide in urethral examination, viz., that the 
meatus urinarius is a measure of the size of the normal 
canal.\ 

What I desire now to make prominent is the fact that 
the best- recognized authorities have long appreciated 
the value of stricture as an agent in the prolongation 
of urethral inflammation and irritation. Whenever it 
could be demonstrated by the imperfect means used, it 

* Handbuch der systematischen Anatomie des Menschen, von Dr. J. 
Henle, p. 417. 

f A constant relation appears to exist between the urethral calibre and 
the size of the penis with which it is associated. This is a fact demon- 
strated by careful measurements with the urethra-meter in several hun- 
dred cases, without a single exception being met. The proportion runs 
as follows: When the flaccid penis measures 3 inches in circumference, 
the size of the urethra will be 30 millimetres in circumference, or more. 
When it is 3^ inches, it will be 32 or more; 3-J inches, 34; 3f inches, 36; 
4 inches, 38; 4^ to 4^ inches, 40 or more millimetres. When the urethra- 
meter is not available, this proportionate relation may be relied upon as 
not over-estimating the normal urethral calibre in any case. 



GONORRHOEA AND ITS SEQUELS. 347 

was at once accepted as the probable cause of the gleet, 
and it was only when no stricture could be found that 
the surgeon was driven to the use of internal medica- 
tion and topical application. The urethra was vainly- 
explored for stricture, because the instruments in use 
were insufficient. The endoscope was the result of an 
intelligent effort to clear up the diagnosis in cases of 
gleet, where no stricture was found. Desormeaux, 
Cruise and others, discovered the granular spots stud- 
ding the urethra in such cases, and the secret was 
apparently manifest. Topical applications through the 
endoscopic tubes apparently cured some, and gave 
temporary benefit to many ; then an army of young 
endoscopists followed en trai7t, believing, as taught, 
that the granular sensitive spots in such cases would, if 
not subjected to frequent ocular inspection and intelli- 
gent cauterization, result in true organic stricture. 
And yet after months of faithful work in this direction, 
the return of gleet, without new contagion, made it 
evident that the true cause of gleet had not yet been 
reached in such cases. I have the record of at least a 
dozen instances* where the difficulty was shown to 

* The following is the record of a typical case of this sort: 
Mr. W., aged 25, came under my care December 1st, 1872. Contracted 
first gonorrhoea early in June, 1872, was treated by injections locally, 
and alkalies internally, until August 1st, during which time he had no 
freedom from the discharge, nor from the acute suffering. At about this 
time, the vesical neck became involved, and he suffered most from fre- 
quent and painful micturition. Came under the care of Dr. , a 

skilled endoscopist, who discovered numerous granular patches in the 
course of the canal, extending quite into the prostatic portion, and appli- 
cations of a strong solution of nitrate of silver were made through the 
endoscope, which afforded temporary relief; urination still painful every 
hour. By September 1st, the discharge decreased to a slight mucus, 
following the use of pencils of tannin and glycerine. A spell of damp 
weather brought back the purulent discharge, with a return of perineal 
pain and frequency of micturition. Tannin pencils again used, but after 
continuing for four weeks, and no improvement, patient was put to bed, 
and hot hip-baths were administered every two hours, etc., etc. After 
five weeks of various kinds of treatment, local and general, he came to 
me from his bed, December 1st, 1872. On examination I found no diffi- 
culty in introducing No. 20 F. bulbous sound, and discovered a firm 
cartilaginous stricture extending from just within the meatus to half an 
inch back. This I freely cut with Civiale's bistouri cache. Immediately 
following the operation, he expressed himself as feeling "like a new 



348 GONORRHGEA AND ITS SEQUELS. 

be a stricture near the meatus, which nevertheless 
admitted the usual-sized endoscopic tube (22 or there- 
abouts), and where the dependence of the granular 
spots upon this condition was proved by their complete 
disappearance, upon the cure of the contraction, with- 
out the aid of any other treatment whatever. This 
premises a conclusion, arrived at by the experience 
gained in a very large number of cases, viz., that gleet 
is always dependent upon stricture : that, while stricture 
may be present when there is no gleet, whenever there 
is a gleet (in the sense of a chronic urethral oozing or 
discharge), an intelligent and thorough exploration, 
with suitable instruments, will invariably discover a dis- 
tinct contraction of the meatus urinarius, or a readily 
recognized coarctation of the urethra at some point ; and 
further, that the complete restoration of the urethra 
to its normal calibre and suppleness, at the contracted 
points, will be required to warrant the statement that a 
permanent cure has been effected. 

The complete division of stricture has, in my expe- 
rience, resulted uniformly in its complete disappearance 
within a period varying from three months to one year, 
and the cure of gleet has, as a rule, followed the complete 
division of stricture within a period varying from twenty- 
four hours to four weeks after the final operation. 

Let us now consider the various degrees in which 
gleet is presented to the surgeon. 

First. When it is just sufficient to form shreds of in- 
spissated mucus, which are observed on examination 
of the first washings of the urethra during the act of 
urination. 

Second. When it is in the form of a simple, transparent 
exudation, only sufficient to glue the lips of the meatus 

man." The discharge ceased within twenty-four hours, the perineal pain 
and frequency of micturition, and the ardor urince also ceased, and he 
returned to his duties, which were most active, on the following day, 
after having been laid up for over five months. The urethral granula- 
tions subsided and finally disappeared within a few weeks without any local 
or general treatment. His recovery was absolute and complete, and the 
only solution afforded was the division of the stricture at the meatus, to 
which the granular spots in the posterior part of the canal were undoubt- 
edly due. 



GONORRHOEA AND ITS SEQUELAE. 349 

urinarius together, and not even enough to stain the 
patient's linen. 

Third. When, on squeezing the penis and subjecting 
the meatus to pressure (as patients afflicted with gleet 
are very much in the habit of doing), a single drop of 
semi-opaque or creamy purulent fluid may be made to 
ooze out. 

Fourth. When it is met as a thin, profuse, nearly or 
quite painless discharge, easily reduced in amount by 
astringent injections, but as readily returning on their 
withdrawal, and, even if apparently cured, returning 
promptly on the least vinous or sexual indulgence. 

Fifth. When the discharge, thicker, decidedly yellow, 
and persistently profuse, exudes from an inflamed and 
pouting meatus, usually causing much redness and irri- 
tation upon contact with the preputial tissues. 

Each and all the grades or varieties of gleet above 
enumerated and casually described may, it is believed, 
be proved to owe their persistence, if not their ^st- 
ence, to simple, localized, mechanical obstruction to the 
passage of urine. 

The impetus which is given to this fluid during an 
ordinary micturition is of no insignificant character. 
The muscles of the diaphragm, abdomen and perineum 
combine to bear down, press against, support, and steady 
the bladder, while the active agents, the detrusor mus- 
cles, which interlace over the entire organ, exert an ex- 
pulsive force sufficient to overcome the resistance of 
the sphincter vesicas, and to project the urine in a full, 
smooth stream through the urethra, to a distance of 
several feet. This, however, gives but a faint idea of 
the effect which a prolonged resistance to the power 
of the muscular apparatus concerned in emptying the 
bladder may produce. In order to be fully appreciated; 
this should be observed in a person laboring under some 
obstruction to the passage of urine, such as occurs in 
urethral stricture. If the stricture is a slight one it may 
be apparent only in producing a want of rhythm in the 
muscular action of the urethra, which prevents a prompt 
and complete emptying of the canal. Thus it is that 
dribbling, after the act, is occasioned. When the strict- 



350 GONORRHOEA AND ITS SEQUELS. 

lire encroaches to a somewhat greater degree, the 
stream is no longer full and strong, but becomes twist- 
ed, and is projected with less force, and now that the 
patient often finds himself exerting a pressure of many 
extra pounds in bearing down upon the bladder, the 
beginning of the effect of stricture begins to be realized. 
But let the case be one where the stricture has closed 
the urethral lumen, so that a continuous stream is no 
longer possible: the pressure becomes so great, that, 
after a time, not only does the urethra become perma- 
nently enlarged behind the stricture, but the urine is 
pressed backward, from the bladder, through the ureters, 
resulting in dilatation of the delicate tubes to many 
times their normal size, the pelvis of the kidney also 
participating in this forced dilatation, until a positive 
sacculation may be produced. This power by which 
the urine is propelled, certainly furnishes the requisite 
conditions necessary to establish a point of irritation in 
a urethra when stricture is present. It is only necessary 
to establish the fact, that the normal resiliency of the ure- 
thra is diminished at a given point, to prove that, dur- 
ing micturition, a perturbation in the stream must occur 
at such point, even if it is not sufficient to attract atten- 
tion in any way. Hence the slightest contractions as- 
sume an importance which could not be inferred from 
the apparejit freedom from trouble in passing the urine. 
They establish a localized point of friction, and, of 
necessity, an increased excitement in the vessels of the 
part, possibly only enough to disturb the complete 
elaboration of epithelial material, and to cause the 
shreddy deposit of the clear normal secretion to take 
the place ; and this may occur, with very slight, or not 
even the least abnormal sensation being present. The 
presence of the mucoid shreds in the urine may be the 
only evidence of commencing trouble. But a perma- 
nent point of friction, once established, greater than the 
natural conservative power of the surrounding parts is 
able to counterbalance, obstruction is increased by the 
natural aggregation of plastic material at the point of 
irritation. In this way the tendency to recovery is com- 



GONORRHOEA AND ITS SEQUELAE. 35 1 

bated, and a permanent point of inflammatory action is 
established. 

Thus the difficulty, which commenced simply as an 
obstruction to the resiliency of the urethral walls, pro- 
gresses naturally and certainly, to the point of narrow- 
ing to a greater or less degree the calibre of the urethral 
canal. 

The second point of importance is the incomplete 
emptying of the urethra after micturition, which occurs 
as a necessary consequence of anterior contractions. 
If the muscular structure is embarrassed, its function 
is imperfectly performed, and instead of completely 
emptying the canal of its irritating contents, a drop or 
more is retained, either to dribble away slowly within 
a few minutes after urination, or to be held, behind the 
contraction, by a spasmodic action (always readily set 
up in the vicinity of urethral irritations) until chemical 
changes heighten its irritative action, and it becomes 
capable of establishing new points of irritation, such as 
are seen in granular urethritis, so-called. It is not im- 
possible or improbable that, as Desormeaux and Cruise 
have taught, the granular spots found in the urethra in 
cases of gleet may be the beginning of stricture ; but 
it is positively true, that they may be, and most fre- 
quently are, the legitimate progeny of an already-formed 
stricture, anterior to the point of their location, and it is 
equally true that unless stricture has already occurred 
as a result of the granular urethritis, the cure of the an- 
terior co-arctation will result, without other treatment, 
in the disappearance of the granulations, and a complete 
restoration of the canal to its normal condition. The 
treatment of gleet by a systematic introduction of sounds 
and bougies, medicated or otherwise, is based upon the 
idea of a possible co-arctation of the urethra at some 
point. Ordinarily this plan is resorted to in the most 
empirical way, simply because the introduction of sounds 
and bougies is recommended by authorities for the cure 
of gleet. By our most intelligent surgeons, it is directed 
to the dilatation of strictures, which have been sus- 
pected, or detected by the bulbous sound or bougie, 



352 GONORRHOEA AND ITS SEQUELS. 

and with a full appreciation of the probable dependence 
of the gleet upon the presenting- strictures. 

That this plan, intelligently pursued, has often cured 
gleet, no one will for a moment gainsay ; but that it 
permanently removes the cause, no one at this day is 
likely to affirm. Nothing is more distinctly laid down 
in the writings of authorities in regard to the treatment 
of urethral stricture, than that the results of dilatation 
are always of a temporary character. So that it is well 
understood, in cases of the cure of gleet by dilatation 
of the stricture, or strictures, upon which it is depend- 
ent, subsequent dilatation must be kept up indefinitely, 
at varying intervals, in order that the gleet may not 
again be established. For a permanent cure, a complete 
division of the contracting stricture must be had, and 
any treatment which falls short of this will, of necessity, 
fail in doing more than to temporarily remove the ob- 
struction which has been the cause of the gleet. 



GONORRHOEA AND ITS SEQUELS. 353 



LESSON XLII. 

COMPLICATIONS OF GONORRHCEA — BALANITIS AND BA- 
LANO POSTHITIS — PHYMOSIS — PARAPHYMOSIS— FOL- 
LICULITIS — EPIDIDYMITIS — PROSTATITIS — CYSTITIS — 
STRICTURE — REFLEX IRRITATIONS AND NEUROSES. 

Balanitis and balano-posthitis — Definition of — Nature of — When compli- 
cated with contracted preputial orifice — Liable to be mistaken for ure- 
thritis — Results from various causes — May be of simple or of contagious 
origin — Treatment. Phymosis — Definition of — Causes which produce 
it — Palliative measures — Radical cure. Paraphymosis— Definition of 
— Causes of — Early treatment important — Method of procedure — Symp- 
toms of this accident — Liability of being overlooked — Importance of 
early recognition — Case in illustration. Folliculitis — Description of 
follicular sinuses — Situation of — Tendency of such sinuses to keep up a 
urethral discharge — Difficulty of treatment — Remedies and procedures 
found useful — Urethral stricture a common cause of folliculitis — Signs 
and symptoms of its presence — Extension of sinuses by suppuration — 
Urinary fistulse resulting — Varieties of accident caused by escape of 
urine into the peri-urethral tissues — Cases in illustration, showing that 
while in some cases the accident is not important, in others it may re- 
sult in urinary fistulae, and sometimes in extensive extravasation of 
urine. 

Balanitis, and balano posthitis, are terms applied to 
inflammation of the semi-mucous membrane covering the 
glans penis and its preputial reflection. This partaking 
of the nature of both the mucous membrane and the 
integument, when attacked in inflammatory process, pre- 
sents some peculiarities common to both. At first per- 
mitting the exudation of cell elements through its inter- 
stices, but finally resulting in a stripping off of the epi- 
thelium, producing destruction of the superficial layers 
in patches. At this point, it is characterized by a free 
purulent exudation, which, as it always and only occurs 
in association with a redundant prepuce, may, when 
this is contracted at its orifice, be difficult to distinguish 
from the purulent discharge of a urethritis. It is 
termed balanitis, when the inflammation is confined to 
the covering of the glans penis, but when this extends 



354 GONORRHOEA AND ITS SEQUELS. 

to the contiguous mucous membrane, reflected from the 
fossa glandis to the preputial orifice, it receives the 
title of balano posthitis. Like urethritis, it acknowledges 
several causes for its initiation. It may result from the 
irritation caused through retention of the normal seba- 
cious secretions by a redundant prepuce, or through 
the occurrence of herpetic eruptions in this locality. 
Or, it may be caused by the irritating influence of 
vitiated simple secretions of vaginal or uterine origin, 
through sexual contact ; or through the secretions of 
a gonorrhoea, either in the female with whom contact 
has been had, or through the retained secretions of a 
gonorrhoea, previously acquired by the subject of the 
balanitis. In these latter cases, it may be appropriately 
termed an external gonorrhoea. When from simple 
causes, it is readily cured by cleanliness and the appli- 
cation of some simple stimulant or astringent. When 
the result of the extension of a gonorrhoea, the diffi- 
culty is more rebellious, and as is usually the case when 
associated with a contracted prepuce, will require the 
cure of the gonorrhoea, as a preliminary measure. A 
solution of the sulphate of iron of the strength of 5 or 
10 grains to the ounce, will usually cure the simple 
forms, in the course of a day or two, and the occasional 
application of cologne water, will usually harden the 
parts, sufficiently to prevent its recurrence. Circum- 
cision is the only means by which the recurrence of this 
trouble may be permanently prevented. 

Phymosis is that condition of a redundant prepuce 
which is so contracted at the orifice, that its retraction 
over the glans, is rendered difficult or impossible. This 
may result from congenital condition, or from inflam- 
matory causes, recent swelling or cicatricial thickening 
of the preputial tissues. The former may result from 
inflammations from simple or gonorrhoea! causes ; the 
latter is usually incident to the deposition of cicatricial 
material, from chancroidal inflammation, or from syphi- 
litic deposit. Simple balanitis may produce it. Gonor- 
rhoeal inflammation is very likely to, and this without 
the occurrence of balanitis. Hence, in many cases of 
gonorrhoea, complicated with a redundant prepuce, this 



GONORRHOEA AND ITS SEQUELS. 355 

accident often occurs, and usually through the irritation 
of the gonorrhceal secretions confined in the preputial 
cavity. For this reason frequent injections of a weak 
antiseptic or astringent solution, becomes necessary to 
cleanse the parts. For this purpose 5 grains of the sul- 
phate of iron to two ounces of water, or 2 or 3 grains of 
carbolic acid, combined with soakings in hot water, may 
be used, to reduce the inflammatory condition. If this 
does not prove effectual, slitting up the prepuce on the 
superior aspect may become necessary to give effect to 
the foregoing treatment. 

Paraphymosis is that condition of a contracted prepu- 
tial orifice, when, it having been retracted behind the 
corona glandis, cannot readily be drawn forward. The 
constriction thus produced, by consequent arrest of ve- 
nous return, causes the parts to become engorged, in- 
creasing the swelling and inflammation. This, if not 
relieved, may go on to destruction of the preputial tis- 
sues by gangrene. Such an accident is not infrequent 
in the course of a commencing gonorrhoea. On its first 
occurrence, the paraphymosis may be reduced by the 
following method. First, lubricating the parts thor- 
oughly with vaseline or sweet oil, then encircling the 
penis with the forefinger and thumb of one hand, com- 
pressing the glans with the concentrated fingers of the 
other, getting as closely under the constricting band 
as possible, push the glans through the ring formed by 
the tissues of the preputial orifice. Should this proce- 
dure fail after a full and intelligent trial, the constrict- 
ing band must be lifted between the thumb and forefin- 
ger if possible, if not, by the pressure under it of a 
grooved director, and completely divided. The cut 
will immediately become transverse, and with or with- 
out a stitch or two, usually heal by first intention in a 
couple of days. 

Sudden swelling of the preputial tissues, at any time, 
should call attention to the possibility of its being caused 
by this accident of paraphymosis, as from the mobility 
of the parts involved, the integument of the penis may 
easily roll forward, and conceal the point of constric- 
tion, as the following case will illustrate : 



356 GONORRHOEA AND ITS SEQUELS. 

A general surgeon of many years' experience called 
upon me to ask a consultation in a case which he sup- 
posed to be a thrombus of the dorsal artery of the penis 
and a resulting gangrene of the anterior portion of the 
organ. The history was as follows : A young man of 
twenty-four, previously to taking a long walk, for con- 
venience in walking, had swung up his testicles in his 
handkerchief, and fastened them by means of an india- 
rubber band, brought over the penis, at its junction with 
the body. He had worn it, in this position, during a 
walk of several hours, and before getting home, com- 
plained of a sense of discomfort from the tightness of 
the band. This was not so great but that he allowed it 
to remain for an hour or two after his return home, 
when, on taking off the band, he found quite a little red- 
ness and a deep crease was left. On rising in the morn- 
ing, the penis was considerably swollen, and he sent 
for the surgeon, who, on hearing the alleged cause of 
the trouble, ordered rest and a saturnine lotion. The 
swelling and inflammation increased steadily, with some 
pain. By the third day, a spot of gangrene appeared 
on the redundant prepuce, at a point corresponding 
with base of the glans. Diagnosis was, gangrene, 
caused by thrombus of the artery of the dorsum. The 
whole penis was greatly swollen, and anteriorly, of a 
violet hue, with a black slough as large as a quarter, 
dollar about an inch from the extremity of a prepuce. 
The entire destruction of the glans had been accepted, 
by both the surgeon and the patient, and the latter, dur- 
ing the temporary absence of the surgeon in coming to 
see me, had, as he said, tried several times to screw his 
courage up to the point of jumping out of his fifth story 
window. On taking hold of the penis with thumb and 
forefinger, I made a little pressure inferiorly, and the 
uninjured glans penis readily protruded from the open- 
ing caused by the slough. Both surgeon and patient 
were greatly surprised and gratified to find that no 
damage had been done to the glans. The explanation 
of the trouble was soon made plain. A short time be- 
fore taking walk previously spoken of, the young man 
had a connection. The anterior border of a narrow 



GONORRHOEA AND ITS SEQUELS. 357 

prepuce, was forced back of the corona, during the act, 
and the redundant tissue had rolled forward, thus con- 
cealing the accident. The coincidence of the rubber 
band applied over the organ, but which had absolutely 
nothing to do with the subsequent trouble, caused the 
error in diagnosis. The attempt of nature to effect a 
circumcision in this case, was supplemented by an ex- 
cision of the remaining portion of the prepuce, and the 
case went on to a satisfactory termination in a few days. 
Folliculitis. — One of the possible causes of a continu- 
ance of a gonorrhceal, or gleety discharge, is the engage- 
ment of the follicular sinuses which open into the urethra 
in the various parts of its course. At the bottom of these 
sinuses, which are of varying size and depth, are the 
glands peculiar to mucous membrane, the so-called mu- 
cous glands of Littre. The minute sinuses leading from 
these, perforate the mucous membrane obliquely; some 
looking forward, and some in the reverse direction, hav- 
ing a diameter from one fifth of a millemetre downwards, 
and varying from one half millemetre to several mille- 
meters in depth. They terminate in follicular, or bag- 
like pouches, or in racemose dilatations, which are im- 
bedded in the substance of the corpus spongiosum. 
These coming to be involved in any inflammatory pro- 
cess of the mucous membrane, when, as sometimes 
occurs, they are of considerable length, may hasten the 
inflammatory process, from various causes, long after the 
remaining portions of mucous membrane have, through 
varied treatment, been restored to a healthy condition. 
This is one of the most difficult troubles to reach, by local 
measures, of all the conditions which tend to keep up a 
chronic urethral discharge. Very thorough cleansing 
of the urethra is necessary to free these crypts and sin- 
uses from the unhealthy secretions which accumulate in 
them, and, inflammation in them creeping out, doubt- 
less, often reinfect the mucous surface in their vicinity. 
Irrigation of the urethra, in these cases, by means of a 
bulb syringe (Davidson's), to which a four or five inches 
of soft rubber catheter is attached, and using half a pint, 
or more, of medicated fluid, at each sitting as originally 
recommended by Mr. Harrison of Liverpool, I have 



358 GONORRHCEA AND ITS SEQUELS. 

often found serviceable in clearing up the remaining 
disease in such cases. 

The sulpho-carbolate of zinc, as suggested by Mr. 
Harrison,* in the proportion of two or three grains to 
the ounce, has, in my experience, proved perfectly effi- 
cacious in a considerable number of cases. Great care, 
however, must be taken to prevent the forcible impinge- 
ment of the injection against the deeper urethra, and 
to make sure that the return stream is not obstucted. 
I have seen several cases where an acute prostatitis or an 
epididymitis could be readily accounted for in no other 
way than that above suggested. The use of a large per- 
forated pipe, attached to an ordinary hard rubber syr- 
inge, as recommended by me several years since, has 
also formed a successful aid to cure in many cases. 
The pipe is made to correspond in size with the normal 
urethral calibre in any given case. In this way, the 
folds of the urethra are obliterated, and the injected 
fluid is thus more certainly brought into contact with 
the diseased follicles and sinuses. Any one of the many 
astringent injections in common use for arrest of gleety 
discharges may thus be used, and often with prompt ben- 
efit. It will, however, be found, that failure of the means 
above alluded to will frequently result. In the majority 
of such cases, a careful examination will discover, 
that the folliculitis is kept up, by localized points of 
stricture, often only slightly narrowing the urethral 
calibre. Behind such strictures, mucus accumulates, 
and is discharged at every urination, in the form of 
shreds or rings of inspissated mucus. In certain cases 
the follicular sinus may be closed, and the suppurative 
process burrows into the adjacent tissue, and may thus 
find its way, by a fistulous canal, opening at some point, 
either in the vicinity of the frenum, which is common, 
or on the under surface of the penis, further back. Or it 
may stop at any point, and form a hard bunch, a ne- 
oplasm, which remains stationary for months or years. 
Or, again, suppuration may occur, and, opening back 

* Harrison on " The Surgical Disorders of the Genito-Urinary Organs," 
London, 1880, page 12. 



GONORRHOEA AND ITS SEQUELAE. 359 

into the urethra, permit subsequent passage of more or 
less urine into its cavity, increasing- the inflammatory and 
suppurative action, in proportion to the amount of urine 
exuded. This accident is more likely to occur during" 
the acute stage of gonorrhoea ; the neoplasm is more 
common in long-standing gleet. 

It will thus be seen that we may have three varieties 
of accident resulting from a folliculitis: 1st, a simple 
extension of the sinus, from burrowing through pro- 
longed inflammation of a low grade, finally opening, in 
some cases, externally, about the meatus, or in the vicin- 
ity of the frenum ; 2d, the exudation into it, of a trace 
of urine, sufficient to cause a plastic exudation, and a 
hard bunch, varying from the size of a small pea to a 
filbert. The connection with the urethra being cut off 
it may thus remain for months or years ; 3d, when the 
processes are more active from instillation of an in- 
creased amount of urine, an acute abscess results, or 
through the ulcerative process, an extravasation of urine 
into the surrounding tissues, may occur, so extensive as 
to cause extensive infiltration and sloughing. 
Thus as illustrative of the first variety : 
A young man came to me presenting a pustule the 
size of a pin's-head, on the right side of the meatus 
urinarius, midway of the glans, and about one-third of 
an inch from the orifice. Believing it to be the result 
of a vicious connection four days previous (as it had 
quite the appearance of a follicular chancroid), I caute- 
rized it with a fine glass point charged with nitric acid, 
and felt warranted in giving the assurance of speedy 
cure. Two days following, the patient presented him- 
self, with the lesion cicatrized, but a similar pustule had 
developed about a quarter of an inch above the site of 
the first. Confirmed by this, in my view of the chan- 
croidal origin of the difficulty, the second was likewise 
touched with the nitric acid. On the following day my 
patient again presented himself, announcing that the 
first pimple had again broken out, and that he also had 
the clap. Making pressure of the glans, a drop of 
creamy pus exuded from the meatus, and also a minute 
quantity of the same sort from the two little orifices on 



360 GONORRHOEA AND ITS SEQUELS. 

the site of the pustules. Struck with the similarity in 
location and appearance of these little opening's with 
those of Case I., I at once set about exploring them. A 
fine silver-wire probe passed readily into one and out 
at the other; the lower seemed superficial. Into the 
upper, however, I succeeded in passing the probe 
nearly half an inch backward and upward, on a plain 
parallel with the urethra. Feeling certain that a com- 
munication existed, through this sinus, with the ure- 
thra, I introduced as far as I was able the blunted point 
of a line hypodermic syringe ; and, having previously in- 
sinuated a bit of lint into the fossa navicularis, I injected 
a solution of indigo. After several unsuccessful trials, 
at last, on the withdrawal of the lint, it was found 
slightly but distinctly stained with the indigo. Shall 
we infer in this case that the trouble was originally a 
simple folliculitis creeping along an accidental sinus — 
possibly producing it — opening on the surface of the 
glans, and finally breaking also into the fossa; or was it 
of gonorrhceal origin, having its initial point in the exter- 
nal follicular openings and after seven or eight days crop- 
ping out into the urethra ? No solution of continuity 
could be detected in the fossa navicularis, nor was there 
much tenderness at any point. A ten-grain solution of 
the nitrate of silver was injected into the fistula, with 
the apparent effect of closing it entirely.: The passage 
between the two points was slit up and cauterized. 
The gonorrhoea (if it was a gonorrhoea) extended very 
little beyond the fossa navicularis, ran a very mild 
course, and ceased under astringent injections in about 
ten days. 

A second case was in a Mr. D., who came to me two 
years since complaining of a little boil on his penis. 
Examination disclosed a small purulent-looking collec- 
tion between the folds of loose tissue, a little to the 
right of and behind the frenum. Both the surrounding 
inflammation and the swelling were very slight ; there 
was but little accompanying tenderness ; the deposit 
was covered only by transparent cutis. A slight touch 
with the bistoury caused it to discharge three or four 
drops of laudable pus. As there were no venereal an- 



GONORRHOEA AND ITS SEQUELS. 36 1 

tecedents in the case, I remarked that it was probably 
a little sebaceous follicle which had become obstructed, 
and that he would have no further trouble from it. 
Several weeks after Mr. D. called to inform me that he 
was quite well of the boil, but that when he urinated 
the water came out of the side of his penis. On exam- 
ination, I discovered a fine opening-, like a pin-hole, at 
the bottom of a small, funnel-shaped depression on the 
site of the old difficulty. A fine silver- wire probe read- 
ily penetrated it, parallel with the urethral canal, for 
about half an inch. Failing to find my way into the 
urethra by this means, I introduced the blunted hypo- 
dermic syringe, and, on driving in the piston, the fistu- 
lous communication was demonstrated by free dripping 
of water from the meatus. 

The foregoing cases, taken together, appear to me to 
warrant the inclusion of follicular sinuses among the 
possible causes of persistent urethral discharge ; and, 
although I find no mention made of such complications 
in the literature of urethral disease, I venture the opin- 
ion that analogous cases have occurred in the experi- 
ence of many practitioners. 

Case III. — Illustrative of the second variety, is a case 
of a young man, 23, who not long since came complain- 
ing of an unusual moisture of the body of the penis at the 
under surface, together with slight swelling, and redness. 
No especial pain had been complained of^ but the con- 
stant sticky moisture annoyed him. His history was of 
repeated gonorrhoeas of slight character which yielded 
to a few injections, but always left a slight gleety dis- 
charge. A year previous he had consulted a very well- 
known surgeon, who on examination found a hard 
bunch on the under surface of the penis just behind the 
frenum, and evidently involving the urethral tissues. 
After much consideration it was pronounced an initial 
lesion of svphilis, and a systematic mercurial course 
was prescribed. The treatment had been faithfully 
pursued for a full year, and was still kept up. No 
other evidences of syphilis had manifested themselves, 
and the induration had not appreciably lessened. Ex- 
amination showed an erythematous spot, the size of 



362 GONORRHOEA AND ITS SEQUELS. 

a quarter-dollar, on the integument of the penis infe- 
riorly and about an inch behind the base of the glans. 
On palpation, superficial fluctuation was distinct, and a 
little pressure caused an oozing of pus from a central 
opening, not larger, apparently, than the point of a pin. 
Introducing an Anel's probe it passed directly forward, 
until it struck the bunch, which was a dense neoplasm 
about the size of a large pea. The origin of this was 
evidently a folliculitis, for pressure upon the superficial 
abscess caused slight oozing of pus from the meatus 
urinarius. What had caused the reopening of the sinus 
resulting in the suppuration in the tissues contiguous 
to the neoplasm was uncertain. It was very evident, 
however, that the diagnosis of syphilis was an error, 
and the mercurial was discontinued. The abscess was 
opened freely its whole length, and healing occurred 
without difficulty. The fistulous tract was finally closed 
by a 60 gr. sol. nit. argent, introduced by means of a fine 
blunted hypodermic syringe. 

Case IV. — A merchant, aged thirty-five, was seen in 
consultation, in the third week of a sharp attack of gon- 
orrhoea, associated with a very contracted meatus urina- 
rius : a swelling, chiefly of the under surface of the 
penis, was discovered. Pain and difficulty of urination 
were very great; the oedema was very considerable; fluc- 
tuation was distinct. About an ounce of grumous, ill- 
smelling pus was evacuated by a free incision, and char- 
coal and iodoform poultices were alternated with soak- 
ings with very hot water. Notwithstanding this, the 
whole roof of the abcess sloughed out. There could be 
no question from history and behavior of this accident 
that the abcess was of urinary character, and caused by 
a leakage at a point which could not be discovered, but 
which in all probability was behind a stricture of large 
calibre at two and a half to three inches from the 
urethral orifice. No subsequent communication with 
the urethra could be made out, and the case went on 
to complete recovery without further difficulty. 

In illustration of the latter, the third form of trouble 
resulting from urethral folliculitis, is the clinical his- 
tory and treatment of a classical case which was made 



GONORRHOEA AND ITS SEQUEL/E. 363 

the subject of a clinical lesson at Charity Hospital in 
1879, a report of which was made by Dr. Brynberg 
Porter, as follows : 

Case V. — This is of a laborer, twenty-eight years 
of age. He was born in Ireland, but has been in this 
country for the last eighteen years. He is unmarried, 
a laborer by occupation, and was admitted to the hos- 
pital three days ago. His family history is moderately 
good. In 1863 he had an attack of typhoid fever, and 
in 1875, while at New Orleans, suffered from intermit- 
tent fever. In 1866 he had gonorrhoea; since then he 
has suffered from gleet. He has for a long time been 
a hard drinker, but has not taken much of late. About 
a month since he noticed a fresh discharge from the 
urethra, although he had had no recent venereal con- 
nection. He said, however, that just before this dis- 
charge made its appearance he had been drinking 
spirits, and beer, very freely, for several days in succes- 
sion. The difficulty resembled an ordinary gonorrhoea, 
and he suffered a good deal from burning in passing 
his water, although he had no difficulty in urinating. 

He further stated, that some six days since, on going 
to bed, he urinated without the least difficulty. After 
a comfortable night's rest he arose, and attempted to 
pass his water as usual, but found himself entirely un- 
able to do so. During the day, suffering with pain and 
alarm, he called upon a surgeon, who readily inserted a 
catheter into his bladder and relieved him. This dis- 
ability continuing, he was relieved in the same manner 
by catheterization, on the second and also on the third 
day, when he presented for admission into this hospital, 
complaining of pain in the perineum and inability to 
urinate. 

He was found to have a distended bladder, the line 
of dullness extending fully two inches above the pubis. 
He was unable to void a drop of urine. An ordinary 
gum catheter was passed, without difficulty, by the 
house surgeon, and the bladder emptied of nearly two 
pints of urine. A distinct but diffuse swelling was 
found in the perineum, which was also the seat of some 
tenderness and pain, as complained of by the patient. 



364 GONORRHOEA AND ITS SEQUELS. 

Since then he has been on his back, with warm poul- 
tices to his perinaeum, and has had his urine drawn 
regularly twice a day. 

This is the sixth day since the occurrence of his 
retention, and the third of his stay in the hospital. We 
now find him considerably below par in his general 
condition, and presenting pretty clear evidences of 
chronic alcoholism. His tongue is furred and tremu- 
lous ; his skin is dry, dusky, almost jaundiced ; his 
temperature somewhat elevated (101 Fahr.); his pulse 
is quick, not strong, and about 100. 

The moderate febrile disturbance present is readily 
accounted for by the presence of the phlegmonous 
swelling in the perineum, previously referred to. This 
is seen to extend, from the attachment of the scrotum, 
to near the anus ; fully an inch and a half in height, 
inflamed, tender to touch, hard and inelastic, yet not 
imparting to the fingers a sense of fluctuation at any 
point. The evidences are quite clear that an inflam- 
mation has been going on, in the tissues of the perineum, 
for several days, and that suppuration is imminent, or 
has already occurred, although not yet to the extent of 
presenting the physical signs, which we usually rely 
upon to determine the presence of a localized accumula- 
tion of pus, viz., fluctuation. 

The depth and course of the tumor would indicate 
that the inflammatory process is here deeply seated, 
and is not a superficial phlegmon from general causes. 
There is no history of any local injury. The first intima- 
tion of trouble was not pain, such as initiates a simple 
cellulitis, but sudden and complete retention of urine. 
Then came a " feeling of fullness," as the patient de- 
scribes it, which did not bring with it any sensation of 
pain, until the following day, and, even then, no external 
swelling was recognized. 

If, you may ask, the evidences are here opposed to 
the idea of an idiopathic origin of the trouble, how 
shall we be able to explain the matter? The closure of 
the urethra, undoubtedly from a mechanical cause, was 
the first sign of trouble. This leads us to consider 
whether the cause might not have been in the urethra 



GONORRHOEA AND ITS SEQUELAE. 365 

itself. Impaction of a calculus, or the sudden swelling 
of mucous membrane from urethral irritation, may be 
suggested, but the easy passage of an ordinary catheter 
is opposed to this ; and besides, the cause which closed 
the urethra continued to act, and was soon manifest as 
a progressive inflammation, involving, iu a short time, 
all the perineal tissues. What, then, is the cause of this 
sudden local trouble and subsequent inflammation ? 

We are assisted in our answer by reference to the 
progress of events in similar cases. When allowed to 
take their own course, the result, almost invariably, is 
an acute abscess. This, when opened, discharges pus, 
more or less unhealthy in character, and presents evi- 
dences of admixture with urine, in greater or less 
quantity; and, at a period varying in different cases, 
from the date of the opening of the abscess (either spon- 
taneously or by operation), up to two or three weeks, 
results in a urinary fistula. 

A rupture of the urethral wall, has been followed by 
the leakage of urine into the surrounding cellular tissue. 
Sometimes this is so slight, that its only effect, is to set 
up a low grade of inflammation, which produces but a 
limited oedema. Again, in other cases, the urinary in- 
filtration is sudden, and so extensive that nothing but 
the promptest surgical measures will save the patient 
from speedy death. The occurrence of a minute ex- 
travasation would explain satisfactorily the trouble in 
the present instance. But how are we to account for a 
perforation or rupture of the urethral walls in a case 
like the present, when the urethra is sufficiently free 
from stricture to permit the easy passage of an ordinary 
catheter? We are accustomed to associate urinary fis- 
tulas with the results of external violence, or with the 
rupture of the urethra behind a close organic stricture, 
occasioned by pressure of urine from urgent action of 
the detrusor urince muscles. Evidently neither of these 
causes obtained in the present instance, and the perfora- 
tion of the urethral walls can only be explained through 
the insidious progress of a sinus, originating in an ante- 
cedent folliculitis. 



366 GONORRHCEA AND ITS SEQUELS. 



LESSON XLIII. 

Post-mortem demonstrations of Dittel, showing evidence of follicular 
uiceration in proof of extravasation of urine occurring in consequence 
of folliculitis — His claim that shreds and rings of mucus in the urine 
shows predisposition to such accident — Author's explanation of the 
cause of £uch shreds and rings — Examination of clinical case with view 
of ascertaining the presence of strictures of large calibre — Follicular 
ulceration and perforation of urethral walls, resulting in urinary infil- 
tration, supported by ample clinical proof — Case in illustration of the 
manner in which such accident is sometimes overlooked — Other cases 
in proof of frequent occurrence of same errors — Operation of external 
perineal urethrotomy. 

Dittel, of Vienna, was the first to demonstrate, 
through post-mortem examination, that in certain cases, 
when death occurred from urinary extravasation, the 
opening in the urethra, by which the urine escaped, 
was through a single small ulcerated follicle of the mucous 
membrane lining the urethra. He snowed that a simple 
folliculitis, might result in perforation of the urethral 
walls, and that follicular inflammation and ulceration, was 
an accident, very likely to occur upon a previously dis- 
eased condition of the urethra, such as is manifested by 
the presence of mucoid shreds in the urine. Dittel did 
not appreciate fully the significance of these shreds, 
which are washed out of the urethra in urination. He 
recognized the fact that these mucoid shreds, which he 
describes as " inspissated mucus, sometimes single, 
sometimes ring-shaped," occur usually in persons pre- 
viously the subject of gonorrhoea, and he claimed that 
they were evidences of a diseased condition of the urethra, 
predisposing to follicular ulceration. Since his recorded 
observations, however, it has been demonstrated, by 
means of the urethrometer and the bulbous sound, that 
these shreds of mucus are the accumulations, behind a 
stricture, which encroaches, often but slightly, upon the 
urethral calibre. It is readily seen, that such slight 
strictures as would permit the easy passage of a cathe- 
ter might still be sufficient to catch the organic debris, 



GONORRHOEA AND ITS SEQUELS. 367 

in the urine of a person suffering with lithiasis, and thus 
form a point of local irritation, finally involving one or 
more follicles in suppurative inflammation. Or even 
from the increased urinary friction, at a point made 
salient by slight stricture, a similar folliculitis might 
ensue, which, once initiated, should finally result in a 
perforation of the urethral walls. 

Let us examine the urethra carefully in this case, with 
the view of ascertaining, whether or not, such a stricture 
is present. The easy passage of the catheter does not 
prove its absence. We must first ascertain the normal 
dimensions of the canal ; then, and not until then, are 
we prepared to determine whether stricture is present 
or absent. The proportionate relation of the size of the 
penis to that of the urethra is ascertained to be as a rule 
about as 2f to 1. Here we find the penis measuring 
2,i inches in circumference. This multiplied by 25 re- 
duces it to millimetres — in round numbers 87-I — divided 
by 2-|=34+. The urethra would then be 34 m.m. in 
circumference. I will say, however, that this propor- 
tionate relation was discovered by frequent use of the 
urethrometer (which registers size in millimetres). A 
large urethra was observed to be associated with a 
large penis, as a rule, and vice versa. Measurements of 
the penis were made with the ordinary English tape- 
measure, and thus it was found that the penis of 3 inches 
circumference was associated with a urethra of 30 m.m. 
circumference ; a 3 \ inches penis with a 32 m.m. urethra ; 
a 3 \ penis with a 34 m.m. urethra ; and so on, the ure- 
thra increasing 2 m.m. in circumference for every \ 
inch increase in the circumference of the penis. The 
attempt to reduce this comparison, of millimetres with 
inches, makes an ugly fraction, and I usually content my- 
self with a formula, which resulted from the accident of 
having two sorts of measures in my clinical work. 
Here, then, we have a urethra of 34 m.m. The mea- 
tus, however, is found by examination with the bulbous 
sound to be only 22 -f-. For further exploration, the 
urethrometer will be required. This we introduce 
readily to the bulbo-membranous junction. It is easily 
expanded to 34 -f- without pain to the patient. On 



368 GONORRHCEA AND ITS SEQUELS. 

drawing it forward for an inch, its progress is arrested, 
and it requires to be turned down to 24, before it can 
be movedo Examining the figures on the shaft of the 
urethrometer, this point is seen to be at 5 inches from 
the meatus. It is hugged closely for half an inch and 
is again free. I now turn the screw until the indicator 
marks 34 on the dial — when the patient begins to com- 
plain. At this size it comes forward easily to \ inch 
from the meatus, where its size requires reduction to 
22 before it will emerge. If we now accept 34 as the 
normal calibre of the urethra in penile portion, we have 
here demonstrated, two prominent points of contraction 
or stricture ; one at from 4J- inches to 5 of a value of 10 
m.m., and one at the orifice of a value of 12 m.m., the 
interval between these points registering 34. It is then 
very evident that two important strictured points are 
present — the one at the meatus, and the other at 4^ to 5 
inches. The deeper one, although permitting the easy 
passage of the largest instrument which can be passed 
through the meatus, is demonstrated to be a local point 
of obstruction exactly like that described by Dittel, and 
behind which shreds of mucus accumulate — are washed 
out in urination, and thus afford reliable diagnostic in- 
formation of stricture; stricture which suggests the 
liability of follicular inflammation and ulceration, and 
a possibly resulting extravasation of urine. In what- 
ever way we explain the cause or causes, which involve 
urethral follicles in ulcerative trouble, which sometimes 
goes on to perforation and urinary infiltration, we must 
accept the fact, as proven by post-mortem examination 
and ample clinical evidence. 

Retention of urine, followed by perineal swelling 
and inflammation, independently of external violence, 
especially when occurring in conjunction with a urethra 
damaged by previous attacks of urethritis, points clearly 
to the occurrence of such an accident as the one alluded 
to, viz., follicular perforation of the urethral wall and 
extravasation of a greater or less amount of urine into 
the surrounding cellular tissue. 

In the present instance, the conditions past and pres- 
ent, as ascertained by the history of the case and by 



GONORRHOEA AND ITS SEQUELS. 369 

our examination, warrant the conclusion that this phleg- 
mon is the result of a follicular ulceration of the ure- 
thra, through which, to a limited extent, urine has 
escaped. In this view of the matter, but one course is 
open to us, but one way is left by which we can arrest 
the difficulty and save the patient from the impending 
danger of an extensive and perhaps fatal extravasation 
of urine ; and this is to incise the inflamed tissues freely 
down to and into the urethral canal. 

The patient will now be etherized, preparatory to the 
performance of this operation, which is appropriately 
termed " External Peri7ieal Urethrotomy." * In the mean- 
while, I will endeavor still further to impress you with 
the importance and correctness of the proposed opera- 
tion, in the present and in similar instances, by citing a 
case, published, some time since, in the hospital reports 
of one of the medical journals : 

"A patient came in complaining of retention of 
urine. He was readily relieved by the catheter. He 
had a painful swelling in his perinaeum, which was 
duly fomented for several days. The swelling in- 
creased ; fluctuation was finally appreciated, but not 
thought to be sufficient to warrant incision, and it was 
determined to defer the procedure until the following 
day. During the night an extravasation of urine took 
place, extending into the cellular tissue of the scrotum, 
penis, and abdomen. On the occasion of the surgeon's 
visit the next morning, free incisions were made into 
the regions of extravasation, and every care taken to 
counteract the effect of the accident (?); but sloughing 
was extensive and the patient sank under its effects, 
and died a few days after." Such a swelling, associated 
with a close urethral stricture, would at once have sug- 
gested the probable nature of the trouble ; but the easy 
passage of the catheter led to the fatal error of suppos- 
ing that the phlegmon was not of urethral origin. 

A series of cases was reported in the London Medical 
Times and Gazette, of January 4, 1873, where extrava- 
sation of urine and perineal fistulas had occurred, in 

* Gouley on " Diseases of the Urinary Organs "(Wood & Co.), p. 112. 



370 GONORRHCEA AND ITS SEQUELS. 

which no stricture was found, No. 8 or No. 9 English 
catheter being readily passed in each case. The same 
verdict might have been rendered with equal propriety 
in the case before us, viz. : 

In these cases we have seen retention of urine and 
perineal abscess, and no stricture found with No. 8 
and No. 9 English catheter. But, on examination with 
efficient instruments, the urethra, in the case we have 
been considering, has been proven strictured to near- 
ly one third of its normal caliber, at a point corre- 
sponding to the perineal swelling. With the same 
means of diagnosis here made use of, have you a doubt 
that stricture would also have been made out in the six 
cases above reported ? I have not — nor have I a doubt 
but that extravasation would have been prevented in 
those cases by a timely external perineal urethrotomy 
such as we are now about to perform. Perineal swell- 
ing, without external injury, as a rule means urinary 
infiltration to a greater or less extent, and the only safe 
course is to make a prompt incision into it, and at least 
down to the urethra. Also examine for and locate, 
what you will be quite certain to find, namely, stricture 
of greater or less extent, at the urethral orifice, as well 
as at some deeper point, and remove these obstructions 
at the earliest available moment. If this is done 
promptly, it may not be necessary to incise the ure- 
thral walls. Pressure of the urine, during urination, 
at the point where the urethra has been perforated, is 
so much lightened by the removal of anterior obstruc- 
tions that healing 01 the perforation may soon take 
place. The incision meanwhile, not only gives exit to 
accumulations of pus or other morbid fluids, but affords 
security against general urinary extravasation. If the 
strictures are not removed, however, and the excision 
has not been carried into the urethra, the probabilities 
are greatly in favor of a return of the trouble after the 
cavity of the abscess has been obliterated, and the ex- 
ternal wound has healed. The operation will then re- 
quire to be repeated, under additional and perhaps 
most serious disadvantages. An instructive case in 
point may be found on page 296 in my work on 



GONORRHOEA AND ITS SEQUELS. 37 1 

" Urethral Stricture," published by Putnam's Sons. 
Several of Dittel's cases are also to be found in connec- 
tion with the same. 

Operative measures will be initiated here by dividing 
the meatus to the full size of the urethra, viz., 34+* 
This accomplished, I pass a large grooved sound readily 
into the bladder. The instrument is held, lightly but 
firmly, directly in the median line, as a guide to the 
urethra, when we approach it. Now the parts hav- 
ing been shaved, with this broad-pointed scalpel I make 
a deep incision into the tumor, exactly following the 
raphe, from a point at the junction of the scrotum with 
the perinasum, downward, to within an inch of the anus. 
This has divided the integument and superficial fascia 
and gone well into the swollen cellular tissue. Another 
incision in the same line carries us through the deep 
layer of the superficial fascia, and gives exit to a small 
quantity of pus and bloody serum which has been con- 
fined beneath it. Now, with my finger, I distinctly feel 
the sound in the urethra. We might have paused at 
this stage of the proceedings, having laid open the 
abscess and emptied it of its contents. But there was 
good reason to believe the origin of the trouble to be a 
perforation of the urethra, and that the cause of it, the 
stricture, previously demonstrated at five inches, still 
remained capable of continuing the mischief already 
commenced. I therefore carefully continued my in- 
cisions until the point of the scalpel entered the groove 
of the staff. This accomplished, the urethera was laid 
open for the space of half an inch, with the intention of 
giving free vent to urine during urination, and thus 
allow the perforation, through which the infiltration 
occurred, to close. This is doubtless so small that we 
are not likely to find it at present, and it may have been 
included in the incision, or be situated at a point close 
to the stricture. In either case, after the removal of 
the stricture, it will probably heal within a few days. 
Now introducing the 34 bulb into the incision, as I 
push it toward the meatus, it is arrested at about 1 
inch. Introducing it at the meatus it passes readily to 
4^ inches. This space between 4J and an inch anterior 



372 GONORRHCEA AND ITS SEQUELAE. 

to the incision is the strictured point which is believed 
to have caused all the difficulty. I now introduce a 
narrow probe-pointed bistoury and divide the stricture 
on the superior wall of the canal completely, as shown 
by the easy passage of a full-sized bulb through the 
canal and out of the perineal opening. 

Reentering the canal through the incision, I pass the 
instrument readily back into the bladder, thus clearing 
up any suspicions of stricture in this locality. The 
after-treatment in this case will be very simple, and will 
consist in : first, raising and supporting the testicles by 
a broad band of adhesive plaster laid upon the upper 
surface of the thighs. This is placed so as to form a 
sort of shelf upon which the testicles may rest and the 
scrotal tissue be free from any danger of urinary infil- 
tration. Secondly, in keeping the parts clean and well 
disinfected, by syringing the wound gently with a i 
to 60 solution of carbolic acid about three times a 
day. The introduction of a small soft-rubber catheter 
through the wound and into the bladder serves to draw 
off the urine without discomfort to the patient, and pre- 
vents its contact with the freshly wounded tissues. 
The catheter may be retained for the first 48 hours, or 
even four or five days, to advantage, and the urine 
directed into a suitable glass vessel — a female urinal for 
instance — which not only conveniently retains the urine, 
but allows the attendant to see at once whether the flow 
of urine continues, or if the tube is stopped ; in the lat- 
ter case the tube should be cleared at once and the 
bladder washed out with a little tepid water ; after the 
removal of the tube or catheter the patient may void 
his urine, at will, upon a large sponge provided for the 
purpose, or into an ordinary bed-pan. A pledget of lint 
soaked in the carbolic solution and changed after each 
urination will be all the dressing required. In all oper- 
ations on the deep urethra I am in the habit of follow- 
ing them by the introduction of a suppository, composed 
of 10 grains of quinine and \ grain of morphia, in order 
to counteract the nervous shock likely to be occasioned 
by the operation, also to prevent the accession of ure- 
thral fever. 



GONORRHOEA AND ITS SEQUELAE. 373 



LESSON XLTV. 

Another case in illustration of follicular ulceration and urinary extrav- 
asation — Operation for relief in this case — Secondary haemorrhage 
occurring — Mode of procedure in such accident — Extravasation of 
urine into the tissues of the groin and abdominal walls — Treatment of 
such accident — Manner in which extravasated urine finds its way into 
tissues at a distance from the point of urethral rupture — Anatomical 
relations of the deep and superficial faciae explained as accounting for 
the direction an extravasation of urine may take — Another case in 
illustration of the accident of follicular ulceration and consequent uri- 
nary infiltration — Mode of treatment — Necessity of opening into the 
urethra in such cases — Another case in illustration of the various ac- 
cidents which may result from urethral perforation through an ante- 
cedent folliculitis. 

Case VI. — Illustrating the same form of trouble, and the 
treatment necessary . in case of urinary extravasation. 
The patient, a young Irish laborer of 27 years, pre- 
sented himself with a well-marked swelling in the peri- 
neum, which had been coming on slowly for several 
days. It was painful on pressure. The tumor was 
quite hard and resilient, but no fluctuation could be 
discovered. The scrotum was quite cedematous, bright 
pink in color, and almost translucent. The coincidence 
of this condition with perineal swelling indicated to me 
that an extravasation of urine, from rupture of the ure- 
thra, was the most probable cause of the oedema. 
Recognizing that the probable cause of the trouble, was 
a follicular rupture of the urethra, with extravasation of 
urine, I advised immediate operation. This the patient 
would not consent to, although the danger of delay was 
pointed out to him, and he was urged, with an earnest- 
ness born of the consciousness of his peril, to embrace 
perhaps the only chance for life remaining to him. The 
chief of staff, also, deeply impressed with the certainty 
of a fatal result, if the extravasation was allowed to con- 
tinue, pleaded with the patient and appealed to his com- 
mon sense, and love of life, but in vain. I was obliged 



374 GONORRHOEA AND ITS SEQUELS. 

to leave him in this dangerous condition, believing that 
the operation without the consent of the patient was 
not justifiable under the circumstances. I pointed out 
to him grave troubles that would probably ensue un- 
less the bladder was kept empty, and introduced a soft 
catheter. The patient withdrew it, however, during 
the night, and the infiltration as a consequence had ex- 
tended to the suprapubic and inguinal regions, and the 
swellings in the perineum, the scrotum and adjacent 
tissues were still more conspicuous, although no fluc- 
tuation could be made out. Consent to operation was 
now readily obtained. 

The patient having been etherized, I introduced a 
steel sound into the urethra, freely opened the perin- 
eal swelling down to and into the urethra, with a bis- 
toury, and made several incisions into the cedematous 
scrotum. The discharge of fetid pus and decomposed 
urine that followed, clearly showed the correctness 
of my diagnosis. I evacuated by pressure as far 
as was possible, the pus and serous fluid from the 
cedematous tissues, inserted a rubber catheter into 
the bladder through the perineal incision, to secure 
drainage, and maintained it there by securing it to a T 
bandage. 

The hemorrhage during operation was slight and 
recovery from the immediate effects of operation and 
the anaesthetic, good, 

I made no section of the suprapubic and inguinal 
tissues, hoping the extravasated urine in these parts 
would drain off through a rubber drainage tube insert- 
ed through one of the scrotal incisions. 

I ordered nutritious diet for the patient, and he was 
committed to the care of the house staff, the house sur- 
geon being instructed as to the accidents to be appre- 
hended. 

I saw the patient the following day; the scrotum had 
then greatly decreased in size and there was no destruc- 
tion of integument. The inflammatory flush which had 
covered the right side of the abdomen and thigh passed 
slowly off. 

On a day, nearly a week subsequent to opera- 



GONORRHOEA AND ITS SEQUELS. 375 

tion, I was suddenly called to the hospital to see the 
case, which had developed secondary hemorrhage. 
This is one of the accidents to be apprehended in peri- 
neal section. By the time I reached him the patient 
had lost 15 or 20 ounces of blood, which was a great 
deal for a man in his condition. He was pale, with 
rapid pulse, and was being freely stimulated. Super- 
ficial plugging had been resorted to, and ice applied, 
but the blood continued to flow from the bladder and 
penis. The abdominal muscles were rigid as a board, 
from the intense straining of the patient to evacuate the 
bladder, which was filled with clots of blood. 

I passed in a large catheter, to which I attached a 
syringe, withdrew the clotted blood and washed out the 
bladder. I then introduced through the wound and 
into the bladder a canula-a-chemise. This consists of a 
catheter over which a piece of linen cloth about ten 
inches square is passed, a hole being cut for this pur- 
pose just large enough to make the cloth fit the catheter 
snugly. The cloth is then tied on about an inch from 
the eye of the catheter and turned forward. We thus 
have made a sort of umbrella. It is not easy for the 
patient to have this introduced through the sensitive 
wound, and it is all important that it be made as smooth 
as possible. In this case it occurred to me to thoroughly 
smear the cloth with hard soap, until the shoulder at the 
junction of the cloth with the catheter should be ef- 
faced, having done this, on wetting it, it slipped into 
the bladder very readily. 

Sometimes even this pressure will stop the bleeding ; 
if not, open out the folds of the umbrella you have thus 
made, and pack it round the catheter with lint or cotton. 
By this means you are able to exert as much pressure as 
you require. On the following day I again saw the 
patient and found a swelling in the right inguinal re- 
gion, with crepitus indicating decomposition of the tis- 
sue, the canula had stopped the exit of the pus, and pus 
and gas had distended the tissues. I therefore removed 
the canula, evacuated the fetid pus material, passed up 
my director and with a sharp-pointed bistoury made an 
incision two inches long. I washed out the wound 



37^ GONORRHOEA AND ITS SEQUELS. 

with a i to ioo solution of carbolic acid and inserted 
another drainage tube. 

Now the question you would naturally ask is, How 
did the pus and urine get up into this region? I will 
try to make clear to you the relation of the parts and 
the situation of the fascia, and how infiltration may in- 
volve the penis without involving the scrotum, or the 
scrotum and not the penis, and how the urine works 
its way up in the pubic and inguinal regions. 

The arrangement of the superficial and deep perineal 
faciae is such as to separate completely from each other 
the parts anterior and posterior to the membranous ure- 
thra, or that portion of the canal included between the 
anterior and posterior layers of the triangular ligament. 
The anterior layer is continuous with the superficial 
fasciae which, including the bulb of the urethra, extends 
forward on the penis, to its insertion in the glans, com- 
pletely investing it in a membranous sheath, and sepa- 
rating the corpus spongiosum from the corpora caver- 
nosa by a membranous septum, continuous with the 
superficial fascia, enveloping the body of the penis. 
Superiorly this fascia is attached to the symphysis 
pubis, and is lost in the aponeurosis of the suspensory 
ligament of the penis and in the surrounding cellular 
tissue. The posterior wall, or layer of the triangular 
ligament, is continuous with the prostato-peritoneal 
aponeurosis, which, joining the pelvic fascia extending 
forward to its attachment on the inferior surface of the 
pubis, thus encloses the lower part of the bladder and 
prostate. This enclosure has received the title of the 
superior or prostatic chamber. While those parts en- 
closed by the superficial fasciae, extending forward 
from the anterior layer of the triangular ligament, and 
attached superiorly to the suspensory ligament and the 
tissues of the pubis, are known as the inferior penile 
chamber. It will thus be readily seen that extravasa- 
tions of urine, occurring through rupture of the ure- 
thra anterior to the anterior wall of the triangular liga- 
ment, find easy access to the tissues of the penis, and 
may readily ascend through the interstices of the fascia 
at its pubic attachment to the groins and abdominal 



GONORRHCEA AND ITS SEQUELS. 377 

walls, and also by the same route gain access to the cel- 
lular tissue of the scrotum. Accidents to the urethral 
walls behind the triangular ligament are exceedingly 
rare, and thus we seldom meet with urinary extravasa- 
tion into the superior or prostatic chamber. When oc- 
curing, however, its localization will be understood by 
appreciating the fascial boundaries of this region ; and 
the knowledge that through ulceration or rupture it 
may gain access to the cavity of the peritoneum will 
suggest early incision through the rectum. 

The late Dr. Gurdon Buck was the first to discover 
and utilize the arrangement of the superficial perineal 
fasciae, in explanation of the different accidents of uri- 
nary extravasation, and this fascia has hence received 
the title of Back's fascia. A full and admirable account 
of it, with its practical relations to the subject we have 
here cursorily considered, will be found in the fourth edi- 
tion of Bumstead and Taylor on Venereal Diseases, p. 
253 et seq., and also in an elaborate article on the same 
subject, by Dr. Robert F. Weir, in the N. Y. Medical 
Record of Nov. 15, 1879, P- 457 et se( l' 

Cases of perineal swelling may arise in this way : 
A certain amount of irritation is caused by stricture of 
the urethra ; folliculitis results, and through the small 
opening thus made the urine gets into the tissues. For 
a while by natural processes the urine effused is ab- 
sorbed, but finally the opening enlarges, and results in 
urinary abscess, and infiltration. . . . 

Dittel's experience would point to the fact that many 
cases of perineal swelling, such as this, have a follicular 
origin. 

When you meet with perineal swelling, do not wait 
for fluctuation : incise it at once. 

Mr. Z., aged twenty-seven, a patient of the well-known 
and accomplished surgeon, the late Dr. Julius The- 
baud, was seen by me in consultation in February, 1875, 
with the following history: Gonorrhoea twelve years 
previous, recurring gleet for four years, urethral stric- 
ture recognized, treatment by steel sounds, size No. 24, 
passed with some pain. This was repeated at intervals 
of several days for a month ; dilatation not well borne, 



378 GONORRHOEA AND ITS SEQUELS. 

pain and increase of discharge following. A few .days 
previous some uneasiness in the perineum was com- 
plained of and a slight swelling was detected in that 
locality. Circumference of penis 3J. Strictures de- 
fined, one at 2 and another at 3 inches, 24 F., one at 4 
inches, 28 F. It was my opinion that a follicular ulcera- 
tion had occurred behind the deepest and largest stric- 
ture (size 28 F.); that in this manner the urethral wall 
had been perforated ; and that extravasation of a limited 
amount of urine had taken place (an accident similar to 
that described by Dittel in Pitha and Billroth's Hand- 
book of General and Special Surgery, 3d volume, 2d 
division, 6th Book. In this case immediate external 
perineal section was imperative for security against pos- 
sible sub-fascial extravasation. A general consultation 
was at once called, consisting of three more surgeons. 
After careful examination the presence of pus was con- 
sidered probable, but doubts were expressed as to the 
origin of the abscess in the urethra. After a brief dis- 
cussion it was decided to pursue a medium course by 
operating at once and thus avoiding the danger of a 
possible grave urinary infiltration, but to limit the in- 
cision to the peri-urethral tissues. The requisite opera- 
tion was performed by Dr. Thebaud. A little bloody 
serum exuded from the engorged deep tissues, but no 
pus was found. The case went on for a week with- 
out much diminution of the swelling or of the ach- 
ing in the testicles after urination, which had been 
a source of complaint previous to the operation. An- 
other general consultation was called ; consisting of the 
same gentlemen previously associated in the case. Be- 
fore convening some 48 hours had elapsed, during 
which, without apparent cause, a favorable change had 
taken place ; the swelling had begun to decline and the 
perineal wound presented a more healthy aspect. The 
improvement being fully recognized, it was deemed best 
to avoid interference. At the end of a fortnight the 
perineal opening had healed completely, when there was 
a sudden accession of discomfort and the swelling was 
found to have reappeared. The case was again seen 
by me in consultation with Dr. Thebaud and Dr. Rey- 



GONORRHOEA AND ITS SEQUELS. 379 

nolds (Dr. Thebaud's partner), some 48 hours after the 
discovery of the recurrent swelling. External perineal 
urethrotomy was again advised and promptly done by 
Dr. Thebaud, and the stricture at 4 inches (just anterior 
to the perineal incision) was divided with a blunt-pointed 
bistoury. An ounce or so of pus and grumous blood 
was evacuated. Immediate relief of pain succeeded and 
the wound healed kindly and perfectly. The aching in 
the testicles previously spoken of as occurring after 
urination did not entirely disappear. This was attrib- 
uted to the presence of the anterior strictures at three 
and two inches from the meatus. These were thor- 
oughly divided with the dilating urethrotome to 32 F., 
the previously ascertained normal calibre of the canal. 
A slight spongio-corporitis followed the operation, which 
delayed the progress of the case about a week ; after 
which, recovery was steady and rapid, resulting in a 
complete cure of all trouble. A reexamination three 
years after showed complete freedom from any trace of 
stricture. This case appears to me to demonstrate the 
occurrence of urinary infiltration behind a slight strict- 
ure, though in quantity so slight that a slowly forming 
abscess only resulted. The persistence of the trouble 
until the urethra was laid open, and the prompt re- 
covery after that was effected, served to clear up any 
doubts that might had been entertained in regard to 
the urinary origin in trouble. 



380 GONORRHOEA AND ITS SEQUELS. 



LESSON XLV. 

FOLLICULAR SINUSES ASSOCIATED WITH URETHRAL 
CONTRACTIONS, AND REFLEX NEURALGIA. 

Clinical case in illustration of the manner in which folliculitis may result 
in erratic sinuses extending to distant points, and which may be as- 
sociated with varied reflex irritations and neuroses — Urethral contrac- 
tions shown to be the original cause of the difficulty. — Prompt relief to 
all trouble resulting from division of strictures — Analysis of the case 
with illustrative diagram — Permanent cure proving the correctness of 
the position — Explanation of the probable mode in which reflex trou- 
bles are produced in such cases. 

Case VIII. X. Y., physician, aged fifty-seven years ; 
has never had any form of venereal disease ; no vicious 
habits from early childhood. Had a very redundant 
prepuce, which, from frequent attacks of balanitis, be- 
came more or less adherent to the glans penis. Up to 
the age of nineteen years could only uncover one-half 
the glans. By systematic effort, however, during a 
period of six months, the adhesions between the glans 
and the internal reflexion of the prepuce were com- 
pletely broken up. He had no further trouble up to 
the age of twenty-two years, when he married. On first 
intercourse, the frenum (which was very long and at- 
tached at the inferior edge of the meatus) was ruptured, 
occasioning severe haemorrhage, and a considerable 
degree of soreness for several days. He remembered 
no further annoyance up to the year 1857, when, at the 
age of fifty years, he had what was then supposed to 
have been an attack of " dumb ague" (irregular chills 
and fever), which in spite of the usual antiperiodic reme- 
dies, continued for a space of two months. To this a 
jaundice succeeded, and, at about the same time, the 
left side of the scrotum became swollen, red, and heavy ; 
not sore to the touch, except on firm pressure. Heavy 
aching pain felt in the tumor at times, without apparent 
cause. No treatment resorted to except that of sup- 



GONORRHCEA AND ITS SEQUELS. 



381 



URINARY INFILTRATION FROM FOLLICULAR RUPTURE 
RESULTING IN ERRATIC URINARY SINUSES. 




A, Stump of cedematous prepuce. B. Urinary abscess. 
C. Urinary fistula. 



382 GONORRHCEA AND ITS SEQUELS. 

porting the mass with an ordinary suspensory bandage. 
This condition of things remained, without any marked 
change, for five and a half years, (in September, 1873, 
being in low condition from overwork) a small car- 
buncle made its appearance on his nose, and was soon 
followed by another, three inches in diameter, on the 
left side of the neck, which lasted, with much suffering 
and debilitation, for about three weeks. At this time a 
circumscribed cellulitis occurred at the most dependent 
portion of the swollen and indurated scrotum. After a 
few days' poulticing an opening occurred in the integu- 
ment, which discharged pus, and was filled with shreds 
of disorganized tissue, similar in appearance to those 
which had characterized the debris of the antecedent 
carbuncles. For this reason, the scrotal lesion was con- 
sidered by the patient and his attending surgeon, to be 
of a carbuncular nature; there was, however, but a 
single opening. Under simple treatment this supposed 
carbuncular abscess was discharged, fully, in about a 
week, and, by the close of the third day following, had 
filled and perfectly cicatrized. In about a week from 
this time, another circumscribed cellulitis appeared on 
the scrotum, about an inch above the first, passing 
through the same phases, and healing completely in 
about the same time. Another interval of a week, and 
a third abscess, precisely like the previous ones in ac- 
cession and course, occupied the superior portion of 
the scrotum, after the complete healing of which the 
entire scrotum was left quite free from inflammation, 
induration, or any abnormal appearance. During the 
next week, another lesion, apparently of the same na- 
ture, occurred on the corresponding side of the penis, 
three quarters of an inch from the root, giving more 
pain than any of the previous abscesses. This, after 
opening, did not heal, but ran along under the integu- 
ment of the dorsum anteriorly for about an inch, when 
it there " broke through and discharged carbuncular 
cttbris" The two openings were united by a division 
of the intervening integument, which was thin and red. 
The burrowing of pus continued along the dorsum penis 
to the fossa glandis, when the prepuce became com- 



GONORRHOEA AND ITS SEQUELS. 383 

pletely phimosed. An opening into the preputial cavity 
in the vicinity of the fossa glandis soon occurred, and 
pus was freely discharged from the preputial orifice. 
In trying to wash out the prepuce with a syringe, it 
was found that the injected fluid traversed the entire 
length of the dorsum penis, and emerged at the first 
opening. A small collection of pus was found on the 
right side, which likewise opened into the preputial 
cavity. At this time the prepuce was very cedematous, 
and urination was difficult and painful ; the pain ex- 
tended beyond the penis, into the thighs, the calves of 
the legs, and even occupying the entire heels, not only 
when urination was attempted, but at night when the 
patient was endeavoring to sleep. Opiates were given, 
McMunns elixir of opium or chlorodyne, but in small 
doses, from ten to thirty drops, two or three times dur- 
ing the night ; larger doses were not well borne, aggra- 
vating the unrest. After some weeks, the doctor took 
a sea-voyage, hoping for benefit from change, as his 
general health had become greately impaired. After 
being at sea for some twenty days, with no perceptible 
benefit, the swelling of the prepuce suddenly increased, 
and a purple spot appeared on the integument of the 
dorsum, just behind theglans. The tissues at this point 
soon gave way, exhaling a fetid odor, and an opening 
occured about the size of a dime, which became perma- 
nent. The tension of the tissues was now somewhat 
relieved, but urination continued difficult, and the pains 
in the thighs, legs, and heels, which had hitherto been 
felt chiefly at night, now continued throughout the day. 
These were severe, almost beyond endurance, notwith- 
standing the use of opiates internally and various local 
appliances. Returning from the voyage after an ab- 
sence of forty -four days (March, 1874), his surgeon di- 
vided the prepuce superiorly from border to base, the 
incision terminating at the gangrenous opening before 
mentioned. This gave great relief to the dysuria, and 
samewhat mitigated the pains in the thighs, etc., which 
were described as of a heavy, aching character, as from 
cramp, or excessive muscular tension. An aggravation 
of his trouble now occurred from the performance of 



384 GONORRHOEA AND ITS SEQUELAE. 

duties which devolved upon him (as the presiding officer 
of a State medical convention), which induced him to 
submit to further surgical procedure. A portion of the 
swollen prepuce was removed ; as much as was thought 
essential to completely relieve constriction, and to get 
at the bottom of the sinuses, for treatment. The cut 
surfaces of the prepuce were left open and healed 
kindly, with the exception of a small opening under the 
base of the glans, through which, finally, a communica- 
tion was established with the urethral canal. This fistula 
was followed, in the course of three or four days, by a 
second, from within outward, and alongside the first, on 
the opposite side of the median line. After the second 
opening was established there was some relief to the 
passage of urine, but none to the aching pain of the ex- 
tremities. The supposed carbuncular troubles on the 
scrotum and on the penis were each preceded by a dis- 
tinct circumscribed induration, involving the thickness of 
the integument and not movable over the cellular tissue. 
Similar indurations, smaller in size, now appeared on the 
Under surface of the penis, to the number of three, which 
each resulted in a urethral fistula, through which urine 
passed at every urination. These were about half an 
inch from the junction of the penis with the anterior of 
the scrotum, and just to the right of the median line. 
Nothing further was done in the way of surgical inter- 
ference, and no improvement occurred either in the 
urinary difficulty or the penis or in the neuralgia of the 
inferior extremities. Consultations, with more than a 
dozen surgeons to whose notice the case was brought, 
failed to afford the patient any relief. Not one had ever 
seen anything like it. The general opinion was opposed 
to the idea of malignant trouble. The difficulty was 
considered of furuncular origin and to have arisen from 
poverty of the blood, dependent upon overwork. No 
treatment was advised, except that addressed to the 
general building up of the system. One surgeon ad- 
vised amputation of the penis. The patient then de- 
cided to come to New York for relief, arriving on Sep- 
tember 17, 1874, with letters to the principal surgeons 
of this city. He was seen by several, the late the dis- 



GONORRHCEA AND ITS SEQUELS. 385 

tinguished Dr. William H. Van Buren, Prof. Thomas 
M. Markoe, and others. The opinions which an ex- 
amination of his condition elicited were mainly in ac- 
cord with those already mentioned, viz., a disease " re- 
sulting- from poverty of the blood from malaria, etc., 
and excessive use of opium" — causing the neuralgic 
pains, etc., from which the patient continued to suffer 
night and day, and so severely and constantly that a- 
complete demoralization of the patient was imminent. 

Priapism added a new elementx)f distress, and with 
only the hope of obtaining a possible relief from this new 
complication, by means oJ>the^ cold-water coil which I had 
just then contrived, he was referred to me. An exami- 
nation of the penis revealed the condition represented in 
the woodcut which precedes this lesson, executed from a 
drawing which I made, at the time of the patient's first 
visit to me. I found the glans exceedingly sensitive to 
touch. The patient was passing his water chiefly through 
a fistulous opening at the base of the glans, inferiorly. 
The meatus urinarius was contracted to 13 f. Bulbous 
sound 13 f. was passed with much pain, hugged closely 
for one inch until it emerged from the first fistulous 
opening. This opening was also terribly sensitive ; an 
attempt to examine it causing a profuse perspiration 
and much complaint. It admitted with difficulty No. 
26 f., and then passed down without force 2\ inches, 
where it was arrested by a stricture. Bulb No. 23 f. 
passed through, and was felt to be free at 2| inches. 
My own view of the case, based upon the experience 
acquired from previously observed cases, w T here exactly 
the same character and locality of pain had been found to 
be dependent upon urethral contractions, determined me 
to advise complete division of all urethral contractions 
as the best and only means of relief. The propriety of 
this procedure was concurred in by Drs. Van Buren and 
Keyes. The doctor, after becoming fully cognizant of 
my views and reasons for operation, consented to submit 
himself wholly to whatever was deemed necessary to 
carry out the proposed operative procedure. The oper- 
ation was set down for the following day, October 27, 
1874. In consequence of previous engagements, Drs. 



386 GONORRHOEA AND ITS SEQUELS. 

Van Buren and Keyes were unable to be present, but 
advised proceeding with the operation. By my invita- 
tion, Prof. Thos. M. Markoe and Dr. Geo. A. Peters were 
present. The patient was put under the influence of 
chloroform (which he had often taken for relief of his 
pains, and with perfect impunity) by my assistant, Dr. 
Fox ; and I proceeded first to divide, fully and freely, 
the contraction from the meatus urinarius to the first 
fistulous opening, which was of calibre 13 f. This was 
done so that 31 f. bulbous sound could be easily passed. 
I then divided the orifice of the main fistulous opening, 
so that the same bulb could readily enter. An exami- 
nation of the deeper urethra was now instituted, and it 
was found that a large-sized probe passed down for one 
and a half inch, and thence out of the urethra, to the 
right, until it entered, easily, the urinary abscess, situated 
at the root of the penis (marked in the cut), and which 
had existed for several months. (The patient com- 
plained that he always felt pain, on urinating, in this lo- 
cality.) The stricture at 2} inches was then defined by 
23 ; and by aid of my small urethrotome this stricture 
was dilated to 30 f., and divided; 31 solid-steel sound 
was then passed from the meatus, through the entire 
urethra, and into the bladder, without force. When 
the patient came out from the influence of the anaes- 
thetic, he expressed himself as feeling better than for a 
long time. Bleeding was slight. The first attempt at 
urinating was painful, but urine was passed more freely 
than for years. Without opium or any other narcotic, 
he passed a comfortable night, sleeping for nine hours. 
On the following morning, he stated that he had entire 
freedom from all the pains so long endured, and that 
for a similar night's rest he " would, be willing to sub- 
mit to a similar operation every night of his life." 
There was no return of his pain in the thighs, legs, etc. 
After two days, I attempted to pass an instrument for 
the purpose of keeping open the divided strictures ; but 
the pain was so great that I desisted, believing it better 
to wait until the sensitiveness had subsided, even at the 
risk of speedy contraction of the deeper stricture. In 
a week, the patient was out. Went to Brooklyn on a 



GONORRHOEA AND ITS SEQUELS. 387 

visit. A pair of tight pantaloons, and an evening spent 
in playing billiards, caused some return of his nervous 
disturbance in the inferior extremities ; but applications 
of warm cloths to the penis soon relieved him. I then 
proposed to examine the condition of the urethra, and 
found, as I had expected, a recontraction of the deeper 
stricture. On Sunday, November 8.th, Drs. Peters, 
McBurney, and Fox present, I again divided the deep 
stricture under chloroform. From that time to the pa- 
tient's departure to his home, December 1st, he had no 
further trouble. His recovery seems to have been 
complete. He left with the promise to communicate 
with me at once if he had any return of his trouble. 
Among the other results of the operation, the urinary 
abscess on the right side of the root of the penis disap- 
peared entirely, and this within ten days after the first 
operation. The subsequent history of the nervous 
symptoms was one of continued improvement. Recon- 
traction of the stricture at 2\ inches occurred, requir- 
ing a second division, but the reflex symptoms did not 
return, and he had, when heard from in 1881, continued 
in good health. 

My own view of the origin of the trouble in this case 
is that, from some unrecognized cause, a follicle in the 
scrotal portion of the urethra became the subject of in- 
flammatory action ; that this follicular inflammation 
finally resulted in ulceration and the formation of a fine 
and somewhat tortuous sinus, extending from the folli- 
cular point of exit in the urethra, down to the bottom 
of the scrotum ; that the "dumb ague," which the pa- 
tient complained of as occurring at about this time, was 
a urethral fever, and marked the progress of the sinus^ 
which, after reaching the most depending portion of 
the scrotum, remained in great degree quiescent for 
five and a half years ; that the depressed condition of 
health, resulting from general causes, finally brought 
about an active inflammation, terminating in an ab- 
scess at the bottom of the sinus ; that when this uri- 
nary abscess, occurring at the bottom of the scrotum, 
supervened, the cellulitis accompanying it closed the 
sinuous tract for an inch, and, after the first abscess had 



388 



GONORRHOEA AND ITS SEQUELS. 



healed, a second cellulitis occurred at the point to which 
the sinus had been closed by the previous inflamma- 
tion, and the second abscess resulted. The inflamma- 
tion attendant upon this, closing the sinus for another 
inch or so, after a brief period the third abscess occur- 
red. In the same time, and in the same manner, a 
fourth. Finally the integument of the body of the penis 
became involved in the ulcerative process, proceeding 
to the anterior portion of the organ. Inflammatory 
paraphimosis, and the consequent tension of all the 
tissues at this point, naturally gave rise to the urethral 
fistulae which appeared in this vicinity. 




Diagram showing the Locality of the Deep Stricture, Course 
of the Urinary Sinus, and Locality of the Abscesses. 

A, Deep stricture, i, First abscess, connected with 2, 3, 4, and 5, the 
succeeding abscesses, by the sinus, which commenced at A, the point 
of stricture, and extended down to /, the bottom of the scrotum. 

The reflex troubles in this case, appear to me, to be in 
exact accordance with those often found associated with 
urethral stricture, especially at or near the meatus uri- 
narius. They are dependent, possibly, upon implica- 



GONORRHCEA AND ITS SEQUELS. 389 

tion and irritation of nerve-fibres or corpuscles in the 
cicatricial tissue, or upon long-continued interference 
with the discharge of urine, in persons debilitated by 
influences calculated to depress the sympathetic ner- 
vous system. 



390 GONORRHOEA AND ITS SEQUELAE. 



LESSON XLVI. 

EPIDIDYMITIS. 

Manner in which epididymitis occurs — Early symptoms — Anatomy of the 
testicle demonstrated — Symptoms of epididymitis — Causes of the same 
explained — Cases in illustration, showing the influence of the passage 
of urethral instruments in producing the accident — Introduction of 
bougies shown to be a frequent cause of epididymitis — Necessity of avoid- 
ing all introduction of catheters and bougies through the deep urethra 
except under urgent conditions — Course of an epididymitis — Treatment 
— Results of epididymitis — Dangers of permanent emasculation — Ex- 
planation of the manner in which this takes place — Diagnosis of such 
accident — Provisions of nature to obviate this danger— Symptoms of 
orchitis — Acute hydrocele complicating epididymitis — Symptoms — 
Treatment — Evidences of obstruction of the seminal canals — Manner 
in which this is produced — Treatment necessary. 

One of the most important and interesting of all the 
complications of gonorrhoea is Epididymitis. 

W. B., aged 24, tells us that he had a discharge from 
the urethra, coming two weeks after connection. The 
appearance of a gonorrhceal discharge, so long after ex- 
posure is unusual, but the length of this interval or so- 
called incubation depends a good deal upon personal 
idiosyncrasy. Sometimes the patient will feel an irrita- 
tion almost immediately after contact, which will in- 
crease in severity, until within forty-eight hours there 
will be a discharge. This goes on increasing in quan- 
tity, the inflammation keeping pace with it, from ten to 
even fifteen or more days, until the active stage of the 
disease has passed. We can usually tell, within four or 
five days after an exposure, whether a man is going to 
have gonorrhoea or not, but sometimes the disease comes 
on very insidiously. If the man is not very observant 
the first thing he will notice will be yellowish spots on 
his shirt. How long they have been there he does not 
know. He has had no pain, no discomfort, but he hap- 
pens to notice the discoloration on his shirt. The term 
incubation, is usually applied to the period between the 



GONORRHOEA AND ITS SEQUELS. 391 

time of coition, and the discovery of the disease. This 
term is incorrect, for there is no true incubation in this 
disease. Inflammation is set up immediately on contact, 
and you might just as well talk about a fire in a coal 
pile having a period of incubation, corresponding to the 
time it was smouldering, before its discovery, as to talk 
of an incubation of gonorrhoea. The fire, when ignited, 
begins to burn at once ; it has no period of incubation ; 
nor has the gonorrhoea. 

This patient says that the first thing which attracted 
his attention was a feeling of pain ; then, when he exam- 
ined the locality of it, he found a discharge from his 
urethra. Undoubtedly the discharge was there before 
he felt the pain. It continued. Four or five weeks sub- 
sequently, his testicle began to swell. Such is the com- 
mon history of this complication. First, the gonorrhceal 
disease makes its appearance, goes on for several weeks ; 
finally an epididymitis is developed. It is a very rare 
thing to find an epididymitis coming on sooner than it 
has done in this patient, unless the patient had had pre- 
vious disease, which left his urethra in an unhealthy con- 
dition. The inflammation passes along the urethra 
slowly, until it reaches the vicinity of the seminal ducts, 
which, as you know, are situated within the prostatic 
urethra. In a very large proportion of cases the in- 
flammation does not reach this point at all ; the gon- 
orrhoea is confined to the anterior portion of the canal. 
But in other cases, from various causes, usually from 
some excess, or from the use of instruments, injections, 
bougies, etc., mechanical irritation ensues, or contagious 
pus is carried down into the prostatic urethra, and an 
inflammation is set up at that point. Passing on, then, 
by continuity of mucous membrane, into the seminal 
ducts, and along the vas deferens, throughout its devious 
course, it finally reaches the epididymis. 

The patient's attention will be called to this latter 
fact, by slight pain, probably first noticed on crossing 
his legs, or by some enlargement of the scrotum. This 
patient says he first felt pain in the lower part of his 
scrotum, and then it went around into his hips and back. 
Now this is not peculiar. The patient, you noticed, 



392 GONORRHOEA AND ITS SEQUELS. 

pointed to the groin, saying he felt pain there. Then 
he swung his hand around to his back. There is a rea- 
son for this; it shows the course which the inflamma- 
tion has taken in this case. 

I will now draw a diagram of the testicle and its various 
divisions on the blackboard. Here we have the seminal 
lobules which are separated by fibrous septa. The 
seminal canals, which proceed from the lobules by redu- 
plications from here, what are called the vasa recta, from 
their general straight arrangement ; these run up and 
down as you see here in eight or nine reduplications, 
forming the head of the epididymis, what is called the 
coni vasculosi, from their conical form; and here, again, 
proceeding from these we have farther reduplications, 
forming the body of the epididymis, and the lower por- 
tion, called the tail; then we have this so-called tail, 
terminating in a single canal, which is called the vas 
deferens. Here we see a little vessel, the vas aberrans, 
coming off from it, which is noteworthy, as it sometimes 
produces an interesting complication called a spermatic 
cyst. At this point we have the serous covering of the 
testicle, tunica vaginalis testis. The vas deferens runs 
up along the cord in the inguinal canal, and that is the 
reason why complaint is made of pain in the groin, in 
commencing epididymitis. This patient put his hands 
to his groin when describing the seat of his pain, and 
spoke of a heavy bearing-down sensation accompanying 
the pain. This pain follows the line of the vas deferens, 
from its commencement in the prostate, along the base 
of the bladder, down through the inguinal canal, over 
the pubes, to the epididymis. Here the inflammation 
usually becomes lost in the reduplications of the epi- 
didymis, it being but rare that it involves the testis pro- 
per, producing what is called an orchitis. This patient's 
trouble is confined entirely to the epididymis ; that alone 
is swollen ; the testicle is not affected. 

Now, we may have inflammation, commencing at the 
seminal ducts,following along the vas deferens for a limit- 
ed distance and then subsiding before reaching the epi- 
didymis. I have had the opportunity of seeing a number 
of cases, in which the inflammation evidently extended 



GONORRHOEA AND ITS SEQUELS. 393 

along the mucous membrane lining- the vas deferens, a 
certain distance toward the epididymis, but eventually 
falling short of it. I recall a case in point, an instruc- 
tive one, as illustrating not only inflammatory trouble 
confined to the vas deferens, but one of the common 
causes of epididymitis. A man came under my care 
many years ago with a stricture of the urethra, for the 
relief of which I treated him by the plan of gradual dila- 
tation. After introducing a soft instrument regularly 
three times a week for several months the patient came 
on a day following the use of the bougie, complaining 
of pain in the perineum, which extended along up the 
back and along the loins. I sent him home and to bed, 
and gave him an opiate suppository to be introduced 
into the rectum. The trouble passed off in a day or 
two. On another occasion, also following the introduc- 
tion of a bougie, pain occurred pursuing the same 
course but continuing down the groin, and caused a lit- 
tle aching in the corresponding testicle. Through use 
of measures used in the preceding attacks this passed 
off, and, not yet recognizing the cause of this pain (fol- 
lowing a distinct course from the perineum around the 
bladder and finally extending to the testicle), the instru- 
ment was again passed, and this time the inflammation 
extended down to the epididymis, and the patient had 
a lively time of it with a swollen testicle for some 
weeks. Now, the cause of this inflammation, without a 
doubt, was the introduction of the soft catheter. This 
introduction of bougies into the urethra I wish you to 
note is one of the commonest causes of epididymitis. 
Epididymitis from this cause, I think, is quite as common 
as that resulting from the simple extension of the in- 
flammation of a gonorrhoea. Within the last three 
months an old gentleman of my acquaintance, 7p years 
of age, obliged on account of an enlarged prostate to use 
a catheter every time he passes his urine, has had two 
severe attacks of epididymitis, brought on in this way. 
In this latter case, certainly there could be no suspicion 
of any other cause than the introduction of the cathe- 
ter. The appreciation of such cases as this will make 
you hesitate to use instruments in the urethra when not 



394 GONORRHOEA AND ITS SEQUELAE. 

absolutely necessary. Still farther to impress this point 
upon your minds, I will cite another case recently un- 
der my care, where a man has had recurrent epididy- 
mitis six or seven times. The cause was supposed for 
a time to be the extension of a gleet with which he had 
been afflicted, but on inquiring carefully into the cir- 
cumstances under which the epididymitis appeared, I 
found that every time he had an attack it was immedi- 
ately following the introduction of a bougie which he 
was using by advice of his physician. Sometimes he 
would have an interval of freedom from epididymitis of 
perhaps one or two weeks, when, on introducing an in- 
strument he would have within twenty-four or thirty-six 
hours an attack of epididymitis. When I pointed out 
the probable cause he at once recalled the fact that it 
did not occur except after the introduction of an instru- 
ment. Do not, then, forget that epididymitis may arise 
from the passage of instruments — bougies, sounds, or 
catheters — no matter how gently introduced through 
the prostatic portion of the urethra. 

Do not fail to consider the danger of setting up an 
epididymitis when you are tempted to follow the sense- 
less and dangerous custom of passing a bougie through 
the entire urethra, and into the bladder for the cure of 
gleet. If a patient with gleet is to be benefited by the 
passage of sounds or bougies, it is because he is the sub- 
ject of stricture, and the benefit, when it is afforded in 
such cases, is through the dilatation of the stricture. 
This stricture may be, and most commonly is, situated 
in the anterior part of the urethra, not infrequently at 
the meatus urinarius alone. Why, then, insist upon pass- 
ing an instrument into the bladder for relief of an ob- 
struction in the anterior urethra? In all such cases, if 
you are wise, you will first ascertain the exact locality 
of the stricture and never pass an instrument to an un- 
necessary distance beyond it. The anterior urethra, 
viz., all the part in front of the bulbo-membranous junc- 
tion, may be treated by dilatation or by division with- 
out the slightest danger of setting up an epididymitis. 
It is in the urethra posterior to the bulbo-membranous 
junction in which all the danger and damage from use 



GONORRHOEA AND ITS SEQUELAE. 395 

of instrumental measures arises. Not only resulting, in 
certain cases, in epididymitis, but not a few persons suf- 
fering only from anterior stricture have lost their lives 
from suppression of urine, caused by passing a soft bou- 
gie through the deep urethra, for which there was not a 
shadow of necessity or justification. 

You will observe that the swelling in the present in- 
stance is entirely on one side. This is due to the fact that 
the testicles are entirely distinct organs. They are 
quite as independent of each other as are the eyes or 
hands, the reason for which is, that the power of propa- 
gation shall be made doubly sure. I will soon call your 
attention to further provisions in this same direc- 
tion and speak of the dangers they are liable to from 
this inflammatory trouble. 

In epididymitis the scrotum increases to the size of 
your closed hand or even larger. It is pyriform in 
shape, and becomes of a deep red color and exquisitely 
tender, and is not infrequently associated with a good 
deal of constitutional disturbance. Fever, nausea, gen- 
eral malaise are not unusual conditions during the 
acute attack of epididymitis from whatever cause it 
may be initiated ; but of course we have every grade, 
from that which follows down the vas deferens only a 
little way, to that which extends through all the con- 
volutions of the vas deferens, through the body of the 
epididymis and even into the seminal lobules them- 
selves. It may stop at any point, but as a rule we 
have a more or less feverish condition in proportion to 
the amount of pain and suffering the patient under- 
goes. This may continue for eight or ten days and 
then decline. In this case the trouble has evidently 
been limited to a small portion of the epididymis. 
Oftentimes in gonorrhceal epididymitis the discharge 
disappears entirely until the inflammation of the epidi- 
dymis passes over. It does not disappear permanently, 
as you might hope, but, on the contrary, as soon as the 
inflammation of the epididymis is over, the discharge 
comes back again to suggest to the unwary a repetition 
of the instrumental interference which may have origi- 
nated the difficulty. 



396 GONORRHOEA AND ITS SEQUELAE. 

With regard to the treatment of these cases of acute 
epididymitis, the first thing to do is to put the patient 
on his back. Put him in a condition to rest the in- 
flamed organ, just as you would rest a lame arm 
or an inflamed finger. And even when he is lying down 
you should support the scrotum, and this is most 
cheaply and easily done by cutting off the heel of a 
stocking, making a hole in either side through which 
to pass a string and attach it to a band around the body, 
above the hips. This forms an excellent suspensory 
bandage and has the advantage also of being large 
enough to allow of applications to the scrotum. Poul- 
tices are very excellent, or hot applications of any kind, 
all that has been said in favor of the application of ice 
to the testicle to the contrary notwithstanding. Hot 
applications in my experience have served a better pur- 
pose than anything else ; and the hotter they are, and 
the more constantly they are applied, the better the re- 
sults. You can get beneficial results also from the use 
of anodynes or narcotics. Strammonium, opium, 
tobacco, are all valuable, applied in poultices over the 
inflamed epididymis. I like tobacco better than almost 
anything else for this purpose. This may be used by 
taking a third of a ten cent package of chewing tobacco, 
and mix it up with a hot poultice of ground flax-seed 
of sufficient size to cover the scrotum completely. 
There is no better application according to my ex- 
perience than this. And if the effect of the tobacco is, 
as is sometimes the case, to produce a little nausea, the 
beneficial effects upon the epididymitis will be enhanced 
by just so much. The old-fashioned treatment is not 
much in vogue now. It was rather disagreeable and 
heroic. It consisted in giving tartar emetic and Epsom 
salts in combination so as to produce a pretty free 
effect of both of these remedies; keeping the patient 
well nauseated and his bowels running off with watery 
discharges. This used to be considered the best mode 
of treatment. There can be no question about the 
value of depressants, even of nauseants, in this con- 
dition. I remember many years ago, when surgeon at 
sea, to have occasionally seen patients who came on 



GONORRHCEA AND ITS SEQUELS. 397 

board ship with acute epididymitis. But I would then 
lose track of them for three or four days, and finally 
when again consulted would find them almost well. 
During this interval they had been suffering with sea- 
sickness. I have seen epididymitis improve rapidly 
under this treatment, if it may be so-called, thus prov- 
ing the value of depressants, and nauseants in the 
management of this disease. It is quite possible that 
their use was originally suggested in this way. 

Support is one of the best means of relief and cure. 
Support from the beginning to the end of the case. 
Support even before the beginning of the epididymitis, 
during the latter stages of gonorrhoea, when you may 
suspect that the inflammation is creeping back into the 
vicinity of the seminal ducts. By supporting the 
testicle at this time it may very quickly ward off an 
attack of epididymitis. Nothing is so conducive to the 
development of an epididymitis, under favoring con- 
ditions, as an unsupported, down-hanging testicle and 
a standing patient. Therefore you should always bear 
in mind during the later stages of a gonorrhoea the 
liability to this trouble, and the means of preventing it. 
Give support, then, before the epididymitis takes place, 
and after it has taken place, and during its entire continu- 
ance. Do not discontinue it until after all tenderness 
and swelling have disappeared. Now, that is all I have 
to say about the treatment of the acute stage of an 
epididymitis. This is not a serious condition so far as 
the pain and confinement are concerned. The general 
discomfort resulting from an attack of epididymitis 
does not amount to much, comparatively. It may keep 
a man suffering during a week or a fortnight ; it may 
bother him for four or five weeks, or two months ; but 
this is as nothing compared with the real injury which 
may be going on perhaps without our knowing any- 
thing about it, and that is, the stoppage of this little vas 
deferens which carries the seminal fluid from the testi- 
cle to the urethra. You can see how long it is, being 
convoluted upon itself, capable of being ravelled out 
for a considerable distance, many yards. A plug of 
inflammatory material may obstruct this at any point, 



398 GONORRHOEA AND ITS SEQUELS. 

and if it does so it will just as thoroughly emasculate 
the man, for the time being, as if he had his testicle re- 
moved. Now a man who has an epididymitis, is very 
apt indeed to have some of this plastic material which 
has been thrown out during the course of the inflamma- 
tion, remain in the head of the epididymis, plugging up 
the seminal canal at some part of its course. In a great 
many cases you will find a hard nodule just above and 
behind the testicle, and this means that the plastic 
material obstructs the epididymis at that point, so that 
the man is hermetically sealed so far as the use of that 
testicle is concerned. Then let the same accident occur 
to the other testicle and his case is a pitiable one, and 
yet that is the case of a great many men in the com- 
munity. There are many men who have no children 
and wonder why, who, if they would recall their early 
experiences, would remember that they had at one time 
a swollen testicle, and again at another time another 
swollen testicle, and who might recognize in this fact an 
explanation of their sterility. Even }^ears after, you 
might feel a knot of plastic material in the epididymis 
which has been the cause of the trouble. 

Now, nature has made provision against accidents in 
a very simple way, by giving a man two testicles ; and 
yet it is very evident that the imflammatory accident 
was not calculated on. Nature has been very liberal 
in her provisions for the insurance of the procreation 
of the species, and especially to preserve the virility of 
man. These provisions exist chiefly in the body of the 
testicle. Here you see the testicle is divided up into 
twelve or thirteen or more spaces or partitions, each 
one of which contains a seminal lobule ; and each one 
of these is potent to secrete spermatozoa enough to 
beget as many children as it is ever necessary for one 
man to beget. An injury may interfere with the in- 
tegrity of one or more of these lobules, and yet if one 
remains healthy the man is perfectly virile ;' perfectly 
able to beget children. The inflammation, as I have 
said before, rarely gets down into these lobules, but 
when it does, constituting a true orchitis, the pain is so 
much the greater that this pain sometimes announces 



GONORRHOEA AND ITS SEQUELS. 399 

the fact at once. The difference between the pain of an 
acute epididymitis and that of an orchitis may be 
illustrated by the old comparison between gout and 
rheumatism. Some man who knew about it defined 
rheumatism in this way: if a man puts his thumb into a 
vice and turns it up until he can't possibly stand it any 
longer, that is rheumatism ; then give it another turn 
or two and that is gout. So with the man who has 
epididymitis: he thinks he has all the suffering that he 
can stand ; give him another turn or two and he has an 
idea of the pain of orchitis : that exceedingly unbearable 
inflammatory pain which is caused by the unyielding 
character of the envelope of the testicle, which is com- 
posed of white fibrous tissue and is known as the tunica 
albnginea. The epididymis lies in cellular tissue to 
which the inflammatory action is readily communicated, 
and thus there is no reason why it should not swell, 
and it does often swell very greatly without producing 
a great deal of discomfort. The swelling is not great 
in this patient : the scrotum is not tense ; the tunica 
vaginalis is not prominent ; but remember that this in- 
flammation, instead of limiting itself to the cellular tissue, 
may pass through it to the tunica vaginalis, the serous- 
membrane which supplies the sac with its lubricating 
material. This fluid increases very much in quantity 
in inflammation of this serous membrane ; and the dis- 
tended tunic presses upon the testicle to such a degree 
that very great pain often results, as well as considerable 
constitutional disturbance. You will find the parts 
tense and the man complaining of unbearable pain. 
When you put your finger on the tumor and find that 
it fluctuates you know at once what you have ; you 
know that the inflammation has extended to the tunica 
vaginalis, which has given rise to an increase in the 
serous fluid which is producing the aggravation of the 
patient's troubles, and which can be removed with 
great advantage. In all these cases as soon as you get 
fluctuation you should put in the needle of your hypo- 
dermic syringe and draw out a drachm or two, or more 
of this fluid. It will usually be straw-colored, but if the 
inflammation run pretty high it may be somewhat pink- 



400 GONORRHOEA AND ITS SEQUELAE. 

ish in color. Drawing off this fluid relieves the pain at 
once. I have been called to cases where the pain was 
extreme ; which could not be relieved by opiates, but 
which subsided immediately after withdrawal of a 
small quantity of serum by means of the hypodermic 
syringe. If you will remember to do just this little 
operation in accordance with the indications I have 
described, you will gain great credit, for it will give 
relief from the extreme pain as nothing else will do. 

But we must never forget the grave accident pre- 
viously mentioned, which is often associated with in- 
flammation of the epididymis — this stopping up of the 
seminal canal at some point. Remember that when 
the inflammation has subsided, the surgeon's duty in the 
case is not ended. He must ascertain whether there is 
any hardness left at any point, and if so put the patient 
on a course of treatment just like that which we have 
recommended in cases of syphilis, and for the very 
same reason. We have, as I have often told you, a lot 
of foreign material, healthy enough ; it does not neces- 
sarily produce any irritation, but it is foreign material, 
because it is not wanted. It is obstructive just as the 
same sort of material is obstructive in syphilitic trouble. 
We want to get rid of this, and the only way we can 
get rid of it is by fatty metamorphosis, and we want to 
use the remedy which is best calculated to effect this 
result. Now, hot fomentations may do it by increasing 
the excitement there, and giving the blood-vessels more 
calibre so as to enable them to carry away the material, 
but they will not do so much good after the active stage 
of the disease has passed away. This shows how im- 
portant it is to have our treatment of the inflammation 
in the first place as complete as possible ; and to neglect 
none of the means which will aid in reducing the in- 
flammation, and in carrying away the products of 
inflammation. But there is something more potent 
than fomentations in carrying away the products of 
inflammatory action ; and this is mercury. We apply 
the oleate of mercury locally on these indurations, and 
if we are wise we will give it internally until we find 
the material composing them under its influence melt- 



GONORRHOEA AND ITS SEQUELS. 401 

ing away, and the vas deferens restored to its normal 
patency. This is a point of great importance, and it 
cannot be dwelt upon too strongly, or made too prom- 
inent in considering this subject. 



402 GONORRHOEA AND ITS SEQUELS. 



LESSON XLVII. 

PROSTATITIS. 

Manner in which prostatitis results from gonorrhceal urethritis — Anatomy 
of the prostate gland — Acute inflammation of rare occurrence — Causes 
of — Early symptoms of the accident — Sometimes resulting in abscess 
— Indications of such result — Manner in which abscesses of the prostate 
terminate — In rare cases producing urinary extravasation — Time 
usually required for suppuration to occur — Diseases which may be mis- 
taken for acute prostatitis — Method of correcting errors of diagnosis. 

We have seen how gonorrhoeal inflammation extends 
by continuity of surface along the lining mucous mem- 
brane of the urethra into its prostatic portion, and dip- 
ping into the seminal ducts, which open into the urethra 
at this point, reaches the vas deferens, and travelling 
along its walls, finally reaches the epididymis occa- 
sionally involving even the secreting structure of the 
testicle. This is one of the most frequent and pain- 
ful of the complications of gonorrhceal urethritis. We 
have still another, which, though rarely, occasionally 
occurs, where the inflammation has reached the prosta- 
tic portion of the urethra. The seminal ducts, you will 
remember, open into the urethra on the inner sides of 
the sinus pocularis, which is situated on the inferior 
floor of the urethra, at about the middle of the prostatic 
portion. Along the outer sides of this sinus, open an- 
other series of ducts, ten to twenty in number, which 
communicate by a lining mucous membrane (continuous 
with the urethral) with the substance of the prostate gland 
which surrounds the urethra, and gives its name to this 
portion of its course. The structure of the prostate is 
mostly muscular tissue, arranged in circular bands, which 
surround the urethra, and whose action is involuntary. 
The glandular substance is arranged in pouch-like folli- 
cles opening into elongated canals which go to join the 
ducts previously described. Fortunately for subjects 
of inflammation of the prostatic portion of the urethra, 



GONORRHCEA AND ITS SEQUELS. 403 

this gland is of low vitality, and is not readily involved 
in inflammatory action, so that acute inflammation ot 
its substance is of rare occurrence : even though gon- 
orrhoea! inflammation invade the prostate urethra and 
linger there for weeks and even months, as it is some- 
times known to do. Acute prostatitis occasionally oc- 
curs independently of urethral disease, and may be 
caused by violence done to the gland through urethral 
injections more or less irritant, through unskilled ef- 
forts to pass a sound or a catheter, or even in skilled 
hands, through the forcible distension of the prostatic 
urethra by means of sounds, bougies, or urethral in- 
struments. Excitement from prolonged and frequent 
coitus, also excessive purgation, have been known to set 
up acute prostatitis. To large doses of copaiba and 
cubebs, have been attributed the occurrence of this 
disease. But the excessive use of stimulants, venereal 
indulgence, exposure to hardships or sudden changes 
of temperature during the course of a gonorrhoea, may 
be considered as the most prominent causes of acute 
prostatitis. Onanism and congestion due to stricture 
are occasional causes, especially stricture, far back ; also 
straining and dilatation of the canal by the urine. The 
early svmptoms of this disease are pain and a sensation 
of heaviness in the perineum, frequent desire to mictu- 
rate, pain on micturition, leaving a dull aching feel- 
ing for some time afterward. Pain in the perineum is 
deep-seated and is increased by the erect posture or by 
sudden jarring movements of the body ; the pain often 
shoots up along the spermatic cords, and is often very 
severe in the lower part of the back. There is also pain 
on defecation, and especially after the disease has pro- 
gressed somewhat. A frequent desire to defecate when 
no fecal matter is present in the rectum, and a constant 
sense of distension as from a foreign body in the gut. 
The cause of this will be explained by the introduction 
of your finger, well oiled, into the rectum. It at once 
impinges upon the swollen gland. Which may have en- 
larged from its natural size (which is about that of a 
horse-chestnut) to twice or thrice that size, within forty- 
eight hours from the commencement of the attack. 



404 GONORRHOEA AND ITS SEQUELAE. 

Sometimes the enlargement is slower, however, though 
you may have nearly all the same symptoms present 
before much enlargement takes place. The feces, if the 
bowels were at all constipated would, theoretically, be 
flattened by encroachment of the enlarged gland upon 
the calibre of the rectum. Practically I have never 
verified this. As the disease progresses, you may have 
the difficulty in passing water increased so that urine is 
only voided drop by drop, and even complete retention 
may occur. The pain in the perineum, assuming a 
throbbing character, is an indication of threatened or 
commencing suppuration ; then the occurrence of chills, 
showing that suppuration has occurred. Abscess form- 
ing, and finally opening either into the rectum, the ure- 
thra, the bladder, or by the side of the urethra through 
the perineum, or finally into the cavity of the peritoneum. 
It is said, that in some rare instances, the disease termi- 
nates in gangrene. The probabilities, however, are that 
the disease has in such case been complicated by ex- 
travasation of urine. Fortunately, however, the most 
frequent termination is in resolution, which, under 
proper treatment or favoring circumstances, may take 
place at any point in the course of the disease, before 
suppuration has become established. The usual time 
for the accession of the acute constitutional disturbance 
varies in different cases. In some there is much, in 
others it may even go on, without any very marked 
symptoms, to the formation of pus in from eight to twelve 
days. The only diseases you are at all liable to mistake 
for acute prostatitis are inflammation of the neck of the 
bladder, stone in the bladder. The constant or frequent 
desire to go to stool, the pain after micturition, as well 
as during the passage of water, the flattened form of the 
feces when solid, and lastly and correcting any error 
you can possibly have made, on introduction of the 
finger into the rectum, you demonstrate the enlarged 
and inflamed condition of the gland beyond the chance 
of a doubt. * 



GONORRHOEA AND ITS SEQUELS. 405 



LESSON XLVIII. 

Acute prostatitis continued — Ordinary mode of examination of the rec- 
tum for diagnostic purposes not the most efficient or convenient — Au- 
thor's method — Its advantages explained — Not only the prostate gland 
but the vesicular seminales and adjacent structures within easy reach of 
the finger — Condition of the prostate and vesiculae seminales, and often 
of the bladder readily ascertained through examination by the rectum 
in the manner proposed — Specific medicines and injections to be dis- 
continued on occurrence of acute prostatitis — Treatment of acute pros- 
tatitis — Retention of urine from prostatic enlargement — Catheters best 
adapted for the relief of this accident — Instructions in regard to their 
use — Abcess of prostate diagnosis and treatment of — Chronic pros- 
tatitis — Diagnosis — Treatment — Seminal weakness associated with 
chronic prostatitis — Masturbation usually the cause — Treatment of 
but little avail while this habit is continued. 

This examination will be most conveniently and 
efficiently made, not in the ordinary way, by placing 
the patient on his back and inserting the finger between 
his thighs, but seated in a chair you direct him to 
stand squarely, his back presenting ; have him drop his 
pantaloons and drawers, and, with his knees straight, 
bend forward at a right angle. The anal orifice is thus 
brought directly opposite and at a convenient height 
for the introduction of your finger. This well oiled is 
then passed in. If with some pain, direct him to strain 
slightly and thus loosen the sphincter. Your finger 
will then readily enter its whole length, and you will 
be able to sweep the rectum with it to the greatest 
advantage — reaching easily the prostate in its entire 
extent and also the vesiculae seminales, and the adja- 
cent structures of the pelvis. Pressure with the oppo- 
site hand above the pubis (especially in persons with 
thin abdominal walls) will give still further information 
in regard to the size and condition of the prostate, and 
to some extent of the bladder also. In quite a con- 
siderable proportion of cases you will recognize not 
only the exact size and condition of the prostate, but 
will be able to recognize changes in the size and form 



406 GONORRHOEA AND ITS SEQUELS. 

of the vesiculae seminales — to which the inflammation 
of the prostate not unfrequently extends. 

Should the symptoms of this disease come on during 
an attack of gonorrhoea all specific treatment by medi- 
cines or injections, if in use, should at once be discon- 
tinued. In most cases the discharge ceases in a great 
degree if not entirely on the accession of inflammation 
in a neighboring organ ; the urethra relieved apparently 
by the counter-irritation in its immediate vicinity. 
Whether the discharge ceases or not, we must now give 
our attention to the graver difficulty. If the symp- 
toms come on with much suddenness and severity, free 
local blood-letting by leeches should at once be resorted 
to — ten or twelve and even twenty (if the patient be ro- 
bust) Swedish leeches may be applied to the perineum, 
and followed by hot poultices or fomentations of Indian 
meal or cloths wrung out of hot water and covered 
with oiled silk. If the bowels are constipated a full dose 
of citrate of magnesia or Epsom salts should be given. 
The bowels should be kept soluble by saline aperi- 
ents during the entire course of the attack, as the pas- 
sage of hardened faeces not only gives intense suffering 
to the patient, but aggravates the inflammatory tend- 
ency. Full doses of morphia, say from a quarter to half 
a grain combined with the oleum theobroma — the cocoa 
butter — in the form of suppositories should be intro- 
duced into the rectum as often as once in 4 or 6 hours, 
or even less if necessary to quell the pain. You may also 
combine with this (or use in place of it, if from any idio- 
syncrasy of the patient opiates are not well borne) the 
extract of belladonna in quantity from J to -§- grain, 
until the specific effects of the drug are manifested. 
The acridity of the urine must be counteracted by the 
administration of alkalies — 10 grains of bicarbonate of 
potash, in a couple of Brockedon's wafers, such as I ex- 
hibited to you some time since — or dissolved in muci- 
lage three or four times a day. Flax-seed tea slightly 
acidulated with a little lemon juice is also beneficial as 
a drink. An occasional general bath of water not less 
than ioo° Fahrenheit will give comfort and benefit your 
patient. Hot-water bags contrived for the purpose or 



GONORRHOEA AND ITS SEQUELS. 407 

ordinary rubber bags are admirable for applying heat 
to that part. Sitz baths should be avoided. From the 
position they necessitate the blood gravitates to the 
inflamed parts, and pain is rather increased than re- 
lieved by them. I need not say to you that the recum- 
bent posture must be rigidly maintained throughout 
the course of the disease. Should retention of urine 
occur, it will be necessary to introduce a catheter and 
draw it off. This is an operation of no little difficulty 
in some cases, and one which requires great care and 
knowledge of the nature and situation of the obstruc- 
tion you will be likely to meet with. The swollen pros- 
tate pushes up against the neck of the bladder, forming 
a sort of valve which obstructs the passage of the urine, 
and interferes also with the passage of the instrument. 
A moderate sized silver catheter may be carefully in- 
troduced and passed gently down to the prostatic por- 
tion of the urethra, after the manner I explained to you 
some time since. Arrived at this point, press it gently 
and cautiously onward, until you meet with the valvu- 
lar obstruction previously mentioned ; then pulling the 
penis well forward depress the handle of the instru- 
ment very slowly and carefully, until it enters the blad- 
der. You may find it necessary, and will certainly be 
aided in the operation by introducing the forefinger of 
your disengaged hand into the rectum, and with it 
guide the instrument into the bladder. A gum- elastic 
catheter, if at hand, is better — a conical bulbous one 
can often be made to enter the bladder without much 
difficulty, or the soft rubber catheter stiffened with a 
slight stylet or by my prostatic guide is best of all as a 
rule. The gum-elastic catheter with a short permanent 
elbow is recommended for cases where the third lobe 
is especially enlarged. Where the swelling of the gland 
is considerable it pushes the bladder upwards, elongat- 
ing the neck, and requiring a much longer instrument to 
reach the interior of the bladder than that in use where 
no swelling is present : a long abruptly curved catheter 
named the prostatic catheter is used for this purpose. 
In using any instrument where prostatic obstruction 
exists, keep its point in contact with the upper surface 



408 GONORRHOEA AND ITS SEQUELS. 

of the urethra, and it will usually guide you safely into 
the bladder. The upper portion of the canal being at- 
tached to bony and ligamentous structures, its course is 
with difficulty interfered with, while the inferior aspect 
is surrounded by yielding structures that easily allow 
irregularities and. deflections of its walls to occur. 
When prostatitis goes on to the formation of pus as in- 
dicated by rigors, a throbbing sensation, etc., it is very 
desirable to ascertain as early as possible at what point 
in the gland suppuration has occurred. Abscess rarely 
occurs in the middle lobe ; when occurring in the lateral, 
it is most likely to point into the urethra, and next most 
frequently into the rectum. In either case it is not ne- 
cessary to interfere early, unless retention of urine 
demand it. Careful examination with the finger in the 
rectum may discover the presence of fluid in some 
portion of the tumor, or you may find obscure fluctua- 
tion in the perineum, showing a tendency of the abscess 
to point in this direction. An early incision with a long 
straight bistoury should be made in the tumor at this 
point in the median line, care being taken to avoid the 
bladder on the one hand and the rectum on the other. 
The sooner the pus is evacuated when the tumor points 
towards the perineum, the less trouble you will have ; 
If left to itself, being pent in by the deep perineal fas- 
ciae, extensive burrowing is likely to occur, and in this 
way pus may find its way into the cavity of the peri- 
toneum, when a fatal peritonitis would in all prob- 
ability ensue. 

When the abscess points toward the urethra, it may 
be opened by the point of the catheter when endeavor- 
ing to evacuate the contents of the bladder in case of 
retention : the pus here escapes through the urethra, 
and the danger is that infiltration of urine will take 
place into the cavity of the abscess and the tissues ad- 
jacent. This can only be avoided by drawing off the 
patient's water through a catheter, until the abscess has 
filled up and healed. When the abscess points toward 
the rectum, it may be broken by the straining efforts at 
stool, or, if the fluctuation is well defined, it may with 
advantage be punctured with a curved trocar. No 



GONORRHOEA AND ITS SEQUELS. 409 

after treatment is necessary. I now recall a case of 
this sort, where the abscess was ruptured at stool, and 
went on to a rapid and perfect recovery. Hourly doses 
•jig- gr. calx, sulphurata will limit and may prevent sup- 
puration. 

More or less enlargement of the gland is left after an 
attack of acute inflammation. This is best treated by 
the use of the bromide of potassium in doses of from 
10 to 15 grains three time a day in a little sweetened 
cinnamon water. 

Rest on the back is the great necessity ; milk or plain 
diet and diluents during an acute prostatis. 

There is another form of trouble of the prostate, 
termed by most writers on the subject chronic pros- 
tatitis, which I believe rarely goes on to formation of 
abcess, rarely or never involves the muscular or cellular 
tissues of the gland to any extent, but is confined almost 
entirely to the mucous lining of the ducts and the 
secreting follicles of the organ. (I can find no record 
of subacute inflammation terminating in abscess from 
this cause.) I believe it to be a purely catarrhal in- 
flammation. It sometimes follows a gonorrhoea, but 
most frequently is caused by onanism or excessive 
coitus — generally by the former (onanism) alone. It is 
characterized by a tenderness on pressure over the 
gland, but produces but little if any perceptible en- 
largement. A turbid viscid secretion is poured out in 
greater or less quantity, and most during the act of 
defecation, and usually impresses the patient, and not 
unfrequently the attending physician, with the idea that 
it is a gleety discharge from the urethra, or a seminal 
discharge. Under the microscope it shows epithelial 
scales of the columnar variety with which the prostatic 
canals are lined, and the squamous variety which line 
the secreting follicles ; these are mixed with mucous and 
perhaps an occasional globule of pus. 

The somewhat sudden appearance of this fluid, so 
different in general appearance from the gleety dis- 
charge which may have preceded it, naturally attracts 
the attention of the patient, and its most salient charac- 
teristics suggest to his mind the probability of its semi- 



410 GONORRHOEA AND ITS SEQUELS. 

nal character. Not unfrequently this idea is communi- 
cated to the medical attendant, who, if he is not familiar 
with this disease, and has not brought his microscope 
to bear on it, will be very likely to confirm the notion 
of the patient, and consider the case one of sperma- 
torrhoea. The microscope alone can clear up the 
diagnosis. The scanty appearance of pus will shut out 
the idea of this increased discharge being due to the 
urethral trouble ; the absence of spermatozoa will 
exclude the idea of spermatorrhoea, and the presence 
of the epithelial scales from the canals, and follicles of 
the prostate, will force the conclusion that the discharge 
is diagnostic of catarrhal inflammation of the prostate 
gland. Another point which is also of interest we 
have associated with it as a diagnostic mark also — the 
stream of urine less forcible than natural, and a drib- 
bling at the termination of the urination, which would 
lead you to suspect stricture : but the passage of a full 
sized sound will clear up this source of error. The treat- 
ment of catarrhal inflammation of the prostate should be- 
gin by explaining the condition of things thoroughly to 
your patient, and put his mind at rest as to its true char- 
acter. Remove as far as possible all circumstances 
which may tend to induce unnatural flow of blood to 
the part ; avoidance of venereal act and thought should 
be insisted on. Advise him to sleep on a hard mattress 
and with light clothing and on his side. Cold bathing 
of the parts night and morning ; to avoid eating at night, 
and be careful that his diet at all times is light and 
easily digested, and to keep the bowels in regular order 
by saline aperients — Kissingen and Congress waters or 
the effervescing citrate of magnesia. If this do not 
arrest the difficulty, counter-irritation to the perineum 
by means of tincture of iodine, or if necessary blistering 
ointment, is advised. All local applications are, how- 
ever, only to be resorted to when other means have 
failed, as they make the patient very uncomfortable, and 
are, I believe, of uncertain value. Tannic, acid with 
cocoa butter (ten grains to the ounce), applied with Van 
Buren's cupped sound, nightly, is sometimes beneficial. 
I have in cases that have proved obstinate occasionally 



GONORRHOEA AND ITS SEQUELAE. 41 1 

used injections of solution of the nitrate of silver of a 
strength of from 20 to 30 grains to the ounce — using the 
long syringe loaded carefully with four or five drops only 
of the fluid, and repeating the operation when necessary 
about once in ten days, and never oftener than once a 
week. In hypochondriacs especially, change of air and 
scene. A case which was under my care some time 
since, which, though much relieved by the above meth- 
od for a time, continued to suffer from this prostatic 
discharge, and also from much mental distress on ac- 
count of it, as he intended marrying as soon as he could 
get rid of his discharge. I advised him to go abroad, 
and in every way possible endeavor to forget that he 
was not well — to cease all treatment and all examination 
of the parts, and not to come back under six months. 
After an absence in Europe of three months, he re- 
turned apparently well, married, and had no further re- 
turn of the trouble. 

Occasionally, or rather I should say usually, this dis- 
ease is associated with nocturnal emissions of semen, 
more or less frequent. No treatment other than that 
above recommended is necessary on this account. It 
is well for you to assure your patient that one or two, 
or even twice that number of involuntary seminal 
emissions during the month are not inconsistent with 
perfect health. Sometimes after the discharge has 
disappeared it may be that the patient finds his erec- 
tions are not perfect before the discharge of semen, 
and that during an orgasm the ejaculation is premature. 
This is the result of the relaxed and irritable con- 
dition of the mouths of the seminal ducts, and is a source 
of great trouble when not properly understood. Chronic 
prostatitis as a result of gonorrhceal inflammation is, as 
I have previously mentioned, usually associated with 
increased frequency of involuntary nocturnal emissions. 
This trouble commonly passes away with the disappear- 
ance of the prostatic discharge, but it sometimes oc- 
curs that an attack of gonorrheal prostatitis is not only 
accompanied by increased nocturnal emissions, but that 
it is associated with or followed by a true seminal dis- 
charge occurring during defecation, or mingled with 



412 GONORRHOEA AND ITS SEQUELS. 

the urine of the patient. In all such cases — and I have 
seen many — I am confident it will be found that the 
patients are or have been habitual masturbators, and 
that the disease has been ingrafted upon a diseased 
mucous membrane previously deteriorated by this 
practice. These are bad cases to manage, especially 
if, as sometimes occurs, the vicious practice is still kept 
up. 



GONORRHOEA AND ITS SEQUELAE. 413 



LESSON XLIX. 

CYSTITIS. 

Gonorrhceal cystitis rarely occurring before the third or fourth week of 
the disease — When occurring earlier usually the result of injections or 
instrumental interferance — Other causes — Symptoms of cystitis — 
Treatment — Stricture of the urethra as a cause of cystitis — Clinical 
case in illustration — Prompt relief of threatened cystitis by division of 
stricture — Permanence of cure — Necessity of examination for stricture 
in cases of threatened or present cystitis — Importance of confining ex- 
amination to the anterior or straight portion of the urethra — Explora- 
tion beyond the bulbous portion in such cases always perilous, and, as 
a rule, to be avoided. 

An occasional complication of gonorrhoea, is the ex- 
tension of the disease to the bladder. This rarely 
occurs before the third or fourth week, from gradual 
extension of the inflammation along the urethra. Its 
occurrence, however, is not infrequent through the use 
of injections. 

Even the forcible injection of warm water has been 
known to engraft a cystitis upon a recent gonorrhceal 
inflammation. It is, however, in the later stages of a 
gonorrhoea, when the disease has crept back in a mild 
form into the deeper urethra, that from some especially 
provoking cause the inflammation is suddenly increased, 
and involves the mucous membrane of the vesical neck. 
The effort to drive injections back into the deeper 
urethra in the later stages of gonorrhoea, not unfre- 
quently, results in their entrance into the prostatic ure- 
thra and the bladder, unless care is taken to prevent it. 
Hence the occasional occurrence of irritation causing fre- 
quent and painful urination in the later stages of 
gonorrhoea. Quite frequently indulgence in sexual 
contact, with or without connection, especially if com- 
bined with alcoholic excess, will cause a sudden aggra- 
vation of the urethral inflammation and its extension to 
the bladder. Passage of urethral instruments into the 



414 GONORRHOEA AND ITS SEQUELS. 

bladder in examining for stricture, is a frequent cause 
of setting up inflammation of the vesical neck. 

The symptoms are frequent urination and painful 
spasmodic contractions of the vesical sphincter. The 
amount of urine is small and at the close of the act of 
urination often mixed with blood. No sense of relief 
following. Great nervous irritability usually resulting ; 
rarely any constitutional disturbance. Inflammatory 
disease occasionally extending beyond the vicinity of 
the vesical neck, may involve the entire mucous coat of 
the bladder, and even extend up the ureters and into 
the pelvis of the kidney. 

Treatment requires absolute rest, in the first place. 
Suppositories of morphia, J grain, every four or six 
hours, to quiet spasms and pain. Diuretics, demulcents, 
and diluents as in the acute stage of gonorrhoea, are 
serviceable. Infusion of the dried root of Triticum 
Repens or " dog grass," an ounce and a half to the 
pint of boiling water and adding to this a drachm of the 
bromide of potassium makes an excellent sedative and 
demulcent drink, the whole amount to be taken during 
each day as long as required. Any attempt to wash 
out the bladder would be sure to aggravate the 
disease during the acute stage and as long as pain is 
present. Injections of all sorts, medicated or other- 
wise, are contra-indicated. Warm water injections 
into the rectum are sometimes serviceable, adding a 
few drops of laudanum to each. When the acute stage 
has passed, and there is no longer any pain during or 
following micturition, and yet pus from the bladder is 
still found in the urine, occasional injections of the muri- 
ated tincture of iron, 20 drops to 4 ounces of water, at 
bed-time, are often serviceable. Gonorrhceal cystitis 
is occasionally caused by the added irritation caused by 
stricture at some point in the course of the urethra, and 
this, too, when the calibre of the urethra is only slightly 
reduced. The following case, illustrates the effect of 
this in producing a cystitis, and also the prompt benefit 
accruing from the removal of the stricture : 

Mr. A. D., aged sixty-four, came under my care com- 
plaining of a slight urethral discharge and a sense of 



GONORRHOEA AND ITS SEQUEL/E. 415 

irritation at the neck of the bladder. He had had no 
recent venereal contact, but had experienced several 
gonorrhceal attacks in early life. Examination showed 
a penis 3! inches in circumference, and a meatus urin- 
arius of a capacity of 32 mm. Examination with the 
urethra-metre demonstrated a normal urethral calibre 
of 36 mm., and detected three narrow bands of stric- 
tures at between two and three and a half inches from 
the meatus, each of the value of 6 mm. I advised im- 
mediate division of these comparatively insignificant 
strictures, explaining and asserting my belief that the 
urethral discharge and the irritation referred to the 
neck of the bladder were a legitimate result of the 
holding and detention of gouty urine or its debris be- 
hind these barriers. Mr. D. declined any operative 
procedure with considerable warmth, and a palliative 
treatment (alkaline and diluent) addressed to his gouty 
diathesis was adopted. Improvement in the quality of 
the urine, which soon took place, caused a temporary 
relief from the irritation, and the discharge, which had 
never been profuse, gradually disappeared. The irrita- 
tion returned, however, at the least indiscretion, and I 
was consulted about it every few weeks until February 
2d, 1877, when he again presented, not only with return 
of the discharge and irritation at the neck of the blad- 
der, but with pain in the glans penis and frequent pain- 
ful urination. A small amount of pus was also found in 
the urine. Recognizing the fact that the urethral in- 
flammation had extended to the bladder, I at once put 
Mr. D. to bed, and by posture, milk diet, local and 
general sedation, did what I could to afford relief. 
Notwithstanding this, a general cystitis supervened 
with great prostration, and came very near terminating 
his existence. He finally recovered (after some six 
weeks in bed), so that pus was no longer seen as a 
sediment in his urine, and urination occurred only once 
in six hours. Mr. D. was then sent to the seashore ; 
there he improved in general condition up to June 2d, 
when he returned, complaining of a recurrence of old 
irritation and a gradually increasing frequency of mic- 
turition. This, as on former occasions, was preceded 



416 GONORRHOEA AND ITS SEQUELS. 

by, and now associated with, a slight, painless, purulent 
discharge. I advised a prompt division of the stric- 
tures, claimed by me at the outset to be the cause of the 
urethral and vesical trouble, and now believed by me 
to be restoring the grave perils from which my patient 
had scarcely escaped. The gravity of any operative 
procedure in the face of threatened or advancing cys- 
titis was fully appreciated. Professor Thos. M. Markoe 
(who previously had seen the patient with me during 
the height of the acute inflammation of the bladder) was 
called in consultation. 

Notwithstanding the age of the patient (sixty-four), 
and his still somewhat feeble condition, resulting from 
previous disease, and the imminent threatening of ano- 
ther attack of acute cystitis, it appeared so evident that 
the return of trouble depended upon the presence of the 
strictures that an immediate operation was decided upon. 

In the presence and with the fullest approval of Pro- 
fessor Markoe, I divided the meatus from 32 mm., so 
that a bulbous sound of 38 mm. was freely admitted. 
No. 36 was then passed easily down 2-J inches, where 
it was arrested by the first stricture. The (my) dilat- 
ing urethrotome was then introduced so that when di- 
lated its blade would rise just behind the posterior of 
the three strictures previously measured and located 
between 2\ and 3-| inches. The instrument was then 
turned up to 38 and the strictures divided. No. 36 
bulb was then passed easily through the entire canal to 
the bulbo-membranous junction, and, on withdrawal, 
demonstrated an entire freedom from Stricture. The 
urine was then drawn off with a soft catheter and six 
grains of quinine administered. The haemorrhage fol- 
lowing the operation was insignificant. A slight chill 
occurred about six hours afterwards, immediately fol- 
lowing the act of urination ; this apparantly occasioned 
a rise in temperature of two degrees (101) for a few 
hours. Aside from this there was not the least con- 
stitutional disturbance and but slight pain on urination. 
Within twentyfour hours the intervals between the acts 
of urination had increased from two to three hours, and 
by the fourth day to six hours. 



GONORRHCEA AND ITS SEQUELS. 417 

On the seventh day after the operation he was dres- 
sed and walking- about, and claimed not to have been so 
wholly free from discomfort since his original irritation, 
more than a year previous. The intervals between acts 
of urination gradually increased. The urine became 
more and more free from pus without other treatment 
than that directed to general health, so that in a month 
he was apparently well in every respect ; micturition 
once in five or six hours, and urine free from pus as a. 
visible sediment. A few pus cells still found by mi- 
croscopic examination. 

October 7, 1877, Mr. D. called at my request for are- 
examination of his urethra. The urethra-metre was 
introduced, closed, to the bulbo-membranous junction, 
turned up to 36 F., and by gentle traction drawn through 
the length of the pendulous urethra without meeting 
with the slighest resistance, thus demonstrating the 
complete absence of stricture, over three months from 
the date of operation, no instrument having been in- 
troduced in the interval. Recovery from the cystitis 
may be said to have been complete, although under the 
microscope a few pus cells were still found. There were 
also a few hyaline casts, but the case appears to me to 
prove fully the possible influence of strictures of large 
calibre in producing urethral inflammation, which, ex- 
tending by continuity of surface, may produce a cystitis, 
and even a nephritis. 

In the foregoing case I feel confident that an early 
division of the strictures would have cured the 
urethral inflammation by removing its cause, and that 
this would have prevented the cystitis in the first in- 
stance as surely as it subsequently did. The urethral 
discharge, which had been more or less profuse for the 
year previous, disappeared entirely a short time after 
the division of the strictures, and has not been seen 
since. 

Up to April, 1883, this gentleman has remained well 
in every respect, not the least trace of pus or casts in 
the urine, and a critical examination of the urethra then 
gave not the slightest evidence of re-contraction at the 
site of former strictures. 



418 GONORRHCEA AND ITS SEQUELS. 



LESSON L. 

URETHRAL STRICTURE. 

Urethral stricture a frequent complication of gonorrhoea — Description of 
the urethra — Its uses — Necessity for complete freedom from obstruction 
— Constrictions from various causes — Usually the result of previous 
inflammatory action — Manner in which stricture is formed — True stric- 
ture always surrounds the urethra — Spasmodic stricture— Distinction 
between organic and spasmodic stricture — Causes of organic stricture — 
Congenital narrowings — Usually at or near the urethral orifice — Meas- 
urement in one hundred cases of supposed normal urethrae — Highest 
type of urethral orifice that which corresponds in size with the urethra 
behind it — Reasons for this statement — Lithiasis a cause of urethral 
stricture — Reasons for this — Usual locality of such strictures — Clinical 
case in illustration — Sir Henry Thompson's views in confirmation of 
the capacity of vitiated urinary secretions to cause urethral stricture — 
Sir Benjamin Brodie's and Mr. Listers' views confirming the same. 

In examination for stricture in cases of threatened or 
present cystitis, where stricture is a suspected cause of 
originating or aggravating the trouble, it should be borne 
>in mind that such stricture if present is rarely beyond 
the bulbo-membranous junction and almost never be- 
yond the membranous urethra, and also it should be 
understood that a contracted urethral orifice consti- 
tutes a stricture as potent for keeping up bladder troub- 
les as when situated at a deeper point in the urethra. 
In all examinations entrance into the bladder or even 
beyond the bulbous urethra, as a rule, should be avoided. 

One of the most common as well as the most impor- 
tant of all the complications of gonorrhoea is 

STRICTURE OF THE URETHRA. 

The urethra may be described as an appendage of 
the urinary bladder and of the vesiculas seminales ; its 
office, in connection with the vesiculae seminales, being 
simply to convey the spermatic fluid, and, in its con- 
nection with the urinary bladder, to convey the urine 
from that reservoir to a proper and convenient distance. 
It is provided with no especial organic structure, except 
that which is required for the complete performance of 



GONORRHOEA AND ITS SEQUELS. 419 

its office as a common carrier. To facilitate the pass- 
age of the urine, a propelling power of no insignificant 
character is furnished by the muscular strength of 
the bladder, aided by those of the abdominal parietes 
and the diaphragm. As the urinary fluid is an excre- 
tion, irritating in its nature, its immediate and complete 
discharge from the urethra becomes a necessity ; hence 
this canal is furnished throughout its entire length with 
a resilient muscular surrounding, which, in its normal 
condition, effects this purpose with certainty and com- 
pleteness. In order, therefore, that the fluids which 
find their exit from the body by the urethra, shall pass 
through it with the least possible friction, the chief 
mechanical necessity in its formation is complete free- 
dom from obstruction. Any obstruction, therefore, 
from any cause — congenital or acquired — must, of neces- 
ity, be considered an interference, to a greater or a less 
degree, with the functional perfection of the genito- 
urinary apparatus. Constrictions of the urethral canal, 
from various causes, and at various points, are known 
to occur, and vary from slight interference with its mus- 
cular surroundings to virtual obliteration of the canal. 

Congenital narro wings of the urethral orifice are per- 
haps as common as congenital phimosis ; but this point 
is so much in the line of inflammatory action, from in- 
fantile balanitis and irritations from other causes, that 
it is quite impossible to draw the line, in any case, be- 
tween the congenital and the acquired condition. 
Other than at this point, there is, I believe, no record 
of congenital urethral stricture. Strictures, at all other 
points, are recognized as of inflammatory origin. Any 
inflammation, set up by any cause, which dips below 
the mucous membrane lining the urethra, occasions, of 
necessity, an aggregation of plastic connective-tissue 
material, which, becoming organized in the submucous 
structure, is at once established as a point of obstruc- 
tion in the normal urethral canal, and, when surround- 
ing it (either by interference with the muscular resil- 
iency of its walls, or by contraction of its lumen), this is 
elevated into the importance of a true urethral stricture. 

Stricture tissue is simply cicatrical material, de- 



420 GONORRHOEA AND ITS SEQUELS. 

posited in accordance with the accepted pathological 
law, that persistent irritation of living tissue results in the 
aggregation of germinal cells, and the development of 
connective tissue corpuscles, at the point of irritation. 
These, becoming organized in the submucous cellular 
tissue and the adjacent muscular structure of the cor- 
pus spongiosum, result in a more or less resilient band 
or bands, always completely surrounding the urethra. 
We have then always to deal with a resilient band, con- 
stricting the urethra more or less, at a given point or 
points. It may here be urged that stricture is not al- 
ways a band surrounding the urethra, but that it may 
be on one or the other, above or below, according to 
many authorities. To this I answer, that a true stric- 
ture, always and of necessity completely surrounds the 
urethra. That it may have its origin, its commence- 
ment, at a single point in the circumference, is quite evi- 
dent, but as soon as the calibre of the urethra becomes 
lessened at any point, the resistance to the flow of urine 
which it necessarily occasions, and the resulting inter- 
ference with the harmonious muscular action, pro- 
duces an irritation in its whole circumference at the 
point of contraction, resulting sooner or later in an 
aggregation of fibro-plastic material, not confined to a 
single point in its circumference, but around the entire 
canal. This fact renders it necessary for us, in all cases 
of strictured urethras, to accept the difficulty as one 
of stricture, in its true sense, and not of obstruction at a 
single point. Aside from the evident probabilities in 
such cases, the fact that stricture of the urethra may 
always be released by division at any point in its cir- 
cumference, would be greatly in favor of this propo- 
sition. Practically, then, we may accept the stricture 
as constricting the entire canal at some point. We 
have then a more or less dense, more or less extensive 
resilient band, or circle, of fibrous tissue, contracting 
the urethral calibre at one or more points. 

This is known as true organic stricture, in order to 
distinguish it from so-called spasmodic stricture, which 
is always due to a more or less complete closure of the 
urethra at various points through a spasmodic contrac- 



GONORRHOEA AND ITS SEQUELvE. 



421 



tion of the muscular surroundings of the canal, and is 
chiefly met with in the so-called muscular or membranous 
portion of the urethra, between the anterior and pos- 
terior layers or walls of the triangular ligament. 

In order to make the distinction between the organic 
and the spasmodic varieties of urethral contraction 
more prominent, and to avoid even the possibility of 
confounding the spasmodic difficulty, either theoreti- 
cally or in practice with true organic stricture, the 
term urethrismus has heretofore been employed by me 
during public discussions on its nature and importance, 
and now I believe pretty generally adopted by later 
writers. 

Stricture, that is, always meaning organic stricture, 
is due to various causes : 

1. Congenital narro wings (which are practically 
strictures, and which are found, in or near the urethral 
orifice). 

2. Lithiasis. 

3. Masturbation. 

4. Traumatism. 

5. Gonorrhceal inflammation. 

1. In regard to congenital narrowings, these have 
heretofore been accepted as normal when they did not 
infringe upon the capacity of the orifice sufficiently to 
produce marked difficulty in urination. In the examin- 
ation of one hundred living subjects with the urethra- 
metre — 



I 


was 


13 mm. cir. 


3 


were 


25-I mm 


3 


were 


15 


4 


" 


26" 


1 


was 


16 


5 


" 


27 


2 


were 


17 


3 


« t 


27i 


3 


" 


18 


2 


<< 


28 


3 


<( 


19 


1 


was 


28^ 


1 


was 


19* " 


5 


were 


29 


3 


were 


20 " 


3 


" 


30 


2 


n 


2o£ ■•" 


3 


c« 


3i 


2 


(l 


21 


5 


< < 


32 


5 


1 < 


22 


4 


" 


33 


3 


" 


22i " 


2 


« < 


33i 


1 


was 


23 " 


3 


" 


34 


1 


" 


23i " 


1 


was 


37i 


7 


were 


24 " 









1 


was 


24i " 


100 




24.72 


17 


were 


25 









422 GONORRHCEA AND ITS SEQUELS. 

Average size in one hundred cases, 24.72. 

In no case was the urethra, in the one hundred cases, 
below a calibre of 26 millimeters — ranging from this to 
39 — the average being 32.95. I think, then, that we 
are forced to conclude that the size of the meatus urin- 
arius externus is not in any sense or degree a guide to 
the urethral calibre. 

It is worthy of remark that, in the one hundred ex- 
aminations referred to, notwithstanding the very great 
disproportion between the size of the meatus and the 
calibre of the spongy urethra, no marked trouble on 
that account was noted. These were, however, cases 
which claimed to be free from inflammatory antece- 
dents. It is probably the fact that, as long as the 
meatus escapes inflammatory action, it does not become 
a source of trouble on account of its diminitive propor- 
tions. We may have a meatus from the size of a mere 
pin-hole to the full size which corresponds with the 
calibre of the urethra behind it. None can, perhaps, 
be claimed to be abnormal, as long as the functions of 
the part are well performed ; and hence, in the pre- 
sence of so great variations, it might be difficult to fix 
upon the highest normal type of the meatus urinarius. 
We find, however, that various and grave difficul- 
ties and diseases are occasionally associated with a gen- 
ito-urinary apparatus, where the meatus is not of 
the full size of the canal behind it, and that such 
difficulties are promptly relieved by a surgical pro- 
cedure which permanently enlarges the meatus to 
that size. The fact that such difficulties do not occur, 
when the meatus is of the full size of the canal im- 
mediately behind it, gives additional weight to the 
assumption. The condition, then, of these parts which 
insures the most complete functional integrity, and 
is least liable to become a source or seat of disease, 
and which is also least liable to induce, aggravate, or 
prolong disease in the contiguous parts, may, I think, 
be safely and appropriately accepted as representing 
the highest normal type. Now, by observation of the 
one hundred cases reported, the meatus will be found 
to correspond with the canal behind it, in ten cases, 



GONORRHOEA AND ITS SEQUELS. 423 

while not one exceeds this limit. Besides this, it can be 
most positively proved that contracted meatus pro- 
longs and intensifies gonorrhoea, produces gleet, and is 
the source of varied and grave reflex irritations. 

We can, then, only accept the urethral orifice as ab- 
solutely free from contraction — practically stricture — 
when it completely corresponds and in size with the 
normal urethra behind it. The question of surgical in- 
terference must always be determined by the presenting 
difficulties, direct or reflex, which may, in the light 
of what is now known of the possible influence of such 
contractions, be reasonably attributed to it. 

2/ In regard to lithiasis, or the habitual tendency to 
the deposit, of crystalline material of the urine at a 
higher temperature than that of the blood. The so- 
called " uric acid discrasia," for instance, the habitual 
passage of uric acid crystals, commonly known as the 
" red pepper sediment" or the " brick-dust deposit" is well 
known to be frequently associated with an irritable 
urethra bleeding easily under the slightest examination, 
and presenting exceedingly sensitive points, especially 
when the urethra is naturally thrown into transverse 
folds, as at the peno-scrotal angle. It is also known 
that in a very great majority of persons two or three 
slight contractions of the urethra are present in the 
same locality, where there has been no acute inflamma- 
tion caused to which such contractions may be attri- 
buted ; and furthermore, it is a well recognized fact 
that on the accession of inflammatory urethra trouble 
from other causes, these points are usually the first to 
receive accessions of plastic material, which result in 
well-marked urethral stricture. In making my measure- 
ments of 100 cases of supposed normal urethral with 
the urethra-metre in 1875, it was found that in almost 
every instance there were 2, 3 and 4 distinct ridges at or 
near the peno-scrotal angle, i.e., from one to two inches 
anterior to the junction of bulbous with the membran- 
ous urethra. These were at a point where the mucous 

*See Otis on "Stricture of the Male Urethra : Its Radical Cure." Put- 
nam's Sons, 2d ed., 1882, page 200, et seq. 



424 GONORRHCEA AND ITS SEQUELS. 

membrane would naturally fall into transverse folds, in 
the pendant position of the penis. The occurrence of an 
erection during examination, in one instance confirmed 
this idea, inasmuch as the absence of the ridges was de- 
monstrated with the urethra-metre at 36. But on sub- 
sequent examination of the same organ in flaccid con- 
dition with the urethra-meter, again at 36, three bands 
were distinctly recognized. These folds, then, would 
form inviting recesses for the lodgment of the solid con- 
stituents of the urine during an acid or an alkaline 
dyscrasia. Prolonged or repeated irritations from such 
cause would naturally produce thickenings in these 
folds, soon interfering with their resiliency, so that 
they could no longer be obliterated on the natural dis- 
tensions of the canal ; more or less obstruction to uri- 
nation necessarily results ; in other words, a point of 
irritation has been established, a urethral contraction 
commenced, which, although not perhaps sufficient to 
attract attention, per se, yet on the establishment of a 
gonorrhoea, would be quite sufficient to increase the 
virulence of the disease, and finally to keep up the ure- 
thral discharge indefinitely. In confirmation of this 
view of the formation of non-specific stricture at the 
peno-scrotal angle, I will cite the case of a lad of nine- 
teen years, who gave positive assurance that he never 
had gonorrhoea. He was first conscious of urinary 
difficulty at the age of seven ; but beyond frequency of 
micturition, did not remember any trouble until about 
three years since, when he began to suffer more or less 
pain during and after micturition, and which was re- 
ferred solely to the body of the penis. He was pre- 
sented at my college clinic. Examination resulted in 
the discovery of a vesical calculus measuring i-J inches 
in its long, J of an inch in it short diameter. The litho- 
trite (No. 22 F.), in passing through the urethra, was 
slightly held at about three inches, and then slid easily 
into the bladder ; the stone (uric acid), was readily 
seized and crushed. On withdrawing the instrument, 
a small quantity of the debris held between its jaws, re- 
sulted in a little greater distension of the urethra than in 
its entrance, and arriving at the point before mentioned, 



GONORRHOEA AND ITS SEQUELS. 425 

and which had been the seat of the pain on urination, 
it was sharply and firmly arrested, and quite a little 
force was required for the extraction of the instru- 
ment. This stricture (which I demonstrated with the 
bulbous sound No. 26) must be admitted, as confirma- 
tory of the occurrence of stricture without precedent 
gonorrhoea, and from the fact that he had stone in the 
bladder, the antecedent lithiasis, of several years' dura- 
tion in connection with the arrangement of the urethral 
mucous membrane just alluded to, affords an apparently 
satisfactory explanation of the method by which the 
stricture was formed in this case, which may be accepted 
as typical of a large class. 

Sir Henry Thompson, in his work on " Stricture of 
the Urethra" (second English edition, page 114), 
headed " Causes of Urethritis and thus of Permanent Stric- 
ture," says: "Urine may possess an irritating quality 
from the predominance of an acid or an alkali in it ; a 
persistence of either of these conditions must be recog- 
nized as one of the undoubted causes of organic stric- 
ture. Thus," he says, "Sir Benjamin Brodie states 
that alkaline urine is more likely to produce the dis- 
ease (stricture) than that which is acid, and that per- 
sons secreting the triple phosphate are almost sure to 
have stricture sooner or later." Mr. Liston says, in re- 
ference to attacks of acidity of urine, that " their 
continuance, or frequent occurrence, may lay the founda- 
tion of disease of the urethra." And further, Sir Henry 
Thompson says (ibid., page 115), " Excesses of venery, 
protracted erections, and prolonged intercourse, are 
recognized causes of stricture." Lallemand, Ricord, 
Sir Everard Home, Acton, Gouley, Gross, and others, 
recognized masturbation as a cause of urethral stricture, 
and certainly if we can accept, with Sir Henry Thomp- 
son, excesses of venery, etc., we cannot deny this in- 
fluence to masturbation. I have myself seen several 
aggravated and undoubted cases which fully support 
this view ; and, again, Sir Henry Thompson (ibid., page 
117) says, " The influence of gout and rheumatism are 
undoubtedly causes of spasmodic stricture ; these dia- 
theses, therefore, predispose in this manner to the ac- 
cession of organic stricture." 



426 GONORRHCEA AND ITS SEQUELAE. 



LESSON LI. 

Masturbation as a cause of urethral stricture — The author's experience 
favoring the possibility of such cause — Professor S. W. Gross claims 
stricture as a frequent consequence of masturbation — Five clinical 
cases in illustration — Traumation as a cause of urethral stricture — Ac- 
cidental excision of the tissue of the urethral orifice in circumcision 
causing stricture — Clinical case in illustration — Venereal lesions at the 
urethral orifice a cause, also injuries from passage of urethral instru- 
ments — Blows on the perineum, from various causes, resulting in ure- 
thral stricture — Urethral stricture most frequently resulting from gon- 
orrheal inflammation — Necessity of appreciating pre-existing strict- 
ures — Gonorrhoea always aggravates and often calls attention to 
strictures previously formed — Symptoms and diagnosis of stricture 
following gonorrhoea. 

3d. In regard to masturbation as a cause of urethral 
stricture : I have frequently met with cases of lads 
from 14 to 18 years of age in whom there was no evi- 
dence of lithiasis, nor any history of such difficulty, and 
where there had been no gonorrhceal trouble or any 
traumatic accidents, where well-marked strictures were 
present, constricting the urethra at various points from 
10 to 20 millimetres circumference. In all such cases 
there was a history of excessive masturbation of from 2 
to 5, or 6 years' duration. Prof. S. W. Gross of Phila- 
delphia, one of the most accomplished and valued au- 
thorities in genito-urinary diseases, wrote me in Feb- 
ruary, 1876, the following histories of cases in which 
masturbation was claimed to be the sole cause of 
urethral stricture, adding the results of examinations in 
85 cases of urethral stricture, comprising 147 stric- 
tures, showing the proportion in which the various 
causes of stricture were found to obtain. 



NOTES OF FIVE CASES OF STRICTURE OF THE URETHRA 
FROM MASTURBATION. 

Case I. — Wm. Sharkey, set. 30, has suffered from the 
rational symptoms of stricture for four years. He is 
rather feeble-minded and has occasional attacks of epi. 



GONORRHCEA AND ITS SEQUELAE. 427 

lepsy. The orifice of the urethra shows a calibre of 27 
French gauge, but the penis is short and small. The 
exploratory bulbous bougie detected two strictures ; the 
first being seated at 5 £ " from the meatus, and having a 
calibre of 18 (F. G.); and the second at 6", and of a 
calibre of 14. Urethra irritable. 

On the 9th of September, 1874, at my clinic at the 
Philadelphia Hospital, I ruptured both strictures with 
Voillemier's divulsor up to 30 — that being the normal 
gauge of the urethra. Conical steel bougies were after- 
wards passed at regular intervals ; but he was trans- 
ferred to the epileptic ward of the insane department 
on the 2d of October. 

This man was a confirmed masturbator, and had been 
for years. He never had connection with a female. 
He continued the practice in the insane department, 
and when I examined his urethra, six months subse- 
quently, contraction had taken place to such an extent 
that I could pass only a No. 14 bulbous explorer. 

Case II. — W. R., a private patient, aged 29 years, 
came under my care February 25, 1875, on account of 
a gleety discharge, diminution in the size of the stream 
of urine, retention of a few drops after the urethra was 
apparently emptied, and sexual hypochondriasis, which 
prevented him from having confidence in his virile 
powers. Exploration with the bulbous explorer de- 
tected a very irritable urethra, and a stricture 5-3^/' from 
the meatus, of a calibre of 18. He had practised onan- 
ism from his sixteenth to his twenty-fifth year, but had 
lessened the frequency during the past four years. Up 
to June the 5th, I treated him with tonics, and, locally, 
with the steel bougie and astringent applications, but 
on account of his habits his visits were interrupted. 
At this time the sensibility of the urethra having almost 
entirely disappeared, I induced him to permit me to 
divide the stricture, he having strenuously opposed this 
remedy up to this date. I incised the coarctation with 
my urethrotome, and passed bougies up to No. 30. He 
had no chill, and remained in the house only thirty- 
eight hours. No. 30 was passed at regular intervals for 
three weeks, when I left town for the summer. I ex- 



428 GONORRHOEA AND ITS SEQUELS. 

amined this man's urethra again, and for the last time 
on October 26th, when I found it to be perfectly free 
from obstruction. All his symptoms had disappeared, 
and he had intercourse without difficulty. 

Case III. — A medical student, set. 24 years, consulted 
me on the 14th of May, 1875, on account of prostator- 
rhcea, irritable urethra, and stricture 5f" from meatus, 
of calibre of 17, and 1" long. His health was much 
broken, and he was in a state of constant mental worry 
from the idea that he suffered from spermatorrhoea. 
These symptoms were of two years' duration, and were 
due to masturbation, which he had only left off about 
twenty-six months previously. Having succeeded in 
subduing the irritability of the urethra by bougies, 
astringent applications, and our cauterization of the 
prostatic sinus, and general remedies, on June 16th I 
I divided the stricture from behind forward, with my 
instrument, up to the full calibre of the canal, which 
was 30. He had no chill, and remained in bed 48 hours. 
He passed out of my sight in three weeks ; but his 
sexual hypochondriasis was not improved. 

Case IV. — W. H., set. 21 years, consulted me on the 
1 6th of November, 1875, on account of what he sup- 
posed to be seminal losses, of three years' duration, the 
result of masturbation. He had never had sexual con- 
gress. He had the rational signs of stricture, and the 
exploratory bougie detected one 5 J" from the meatus, 
of a calibre of 13. The meatus was red and pouting, 
and the entire canal was very sensitive. This patient 
consulted me only twice, and objected to operative 
treatment. 

Case V. — A druggist, aged 24 years, was brought to 
me on the 18th of February, 1876, on account of symp- 
toms of vesical irritability, under which he had labored 
for six years. He had never had sexual intercourse, 
but had constantly masturbated from boyhood, until his 
twentieth year. The entire urethra and neck of the 
bladder were excessively sensitive, and a stricture of 
the calibre of 17 was detected 6 T y from the meatus. 
Both epididymes, particularly the right, were enlarged 
and indurated. There was no history of venereal dis- 



GONORRHOEA AND ITS SEQUELAE. 429 

ease. This man had come north to lay in a supply of 
drugs, and I presume I will see him again before he 
returns to the west. 

During the past 18 months I have kept a full history 
of the cases of stricture of the urethra that have fallen 
under my charge. They number 85, and represent 147 
strictures. 

Of their causation, 75, or 88.23 percent were due to Gonorrhoea. 
5, " 5.88 '* " Masturbation. 

3, " 3-53 " " Lithiasis. 

2, " 2.35 " " Traumatism. 

It is noteworthy that, in all the cases due to onanism, 
the urethra was unduly sensitive, and the stricture was 
seated in the curved portion of the urethra. Four were 
single, and one was double. While the proportion of 
gonorrhceal strictures is the usual one, those arising 
from onanism or lithic acid diathesis are beyond the 
average, and had gonorrhoea existed in these cases it 
would probably have been noted as the cause of the 
coarctation and the true antecedent trouble have been 
overlooked. In other words a stricture of the urethra 
of large calibre may exist without any very marked 
rational signs, and be due to inflammation provoked by 
other than specific causes. In such a case an attack of 
gonorrhoea will intensify the trouble, and might be as- 
sumed to be its existing cause. I have now in my ward 
at the Philadelphia Hospital a case of three tight stric- 
tures, attributed by the patient to an attack of gonor- 
rhoea contracted five months before I examined him. If 
the clap be the true cause, I have only to say that it is 
the only case of the kind I have ever met with; as my 
experience goes to show that multiple and narrow 
strictures do not form in so short a space of time." 

In regard to 

TRAUMATISM AS A CAUSE OF URETHRAL STRICTURE. 

It is not a very rare circumstance to meet with 
a contracted urethral orifice from cicatrization, re- 
sulting through the accidental excision of the end of 
the glans penis in the unskillful performance of the 



430 GONORRHOEA AND ITS SEQUELS. 

Jewish rite of circumcision. I have seen several such 
cases, prolonging gonorrhoea, producing gleet, and 
also various reflex irritations. In one case within the 
past year, after a long siege, the gleet had apparently 
been cured by injections, and the patient had received 
permission to marry. The sexual excitement attendant 
upon the first week of marriage reproduced the dis- 
charge and a sharp gonorrhoea was communicated to 
the bride. Complete division of this stricture from 18 F. 
to 35 F. resulted in a cure which now, over 9 months, has 
continued, notwithstanding a rather excessive degree 
of sexual intercourse. Venereal lesions of the meatus 
— the initial lesion of syphilis — also chancroid — are 
a frequent source of stricture at this point. Injuries 
from the passage of urethral instruments and lithotrites 
are not uncommon, resulting in stricture of various 
parts of the urethral canal. Blows in the perineum 
falls astride fences, or their equivalent, violent con- 
tact with the pommel of a saddle, or through falls upon 
the wheel in carriage accidents, these are among the 
most frequent causes of traumatic stricture. From 
the nature of such injury the cicatricial deposit is 
much more extensive and dense than in strictures 
caused by inflammations initiated through the mucous 
membrane of the urethra, and consequently are less 
susceptible of permanent relief from any and all varieties 
of treatment. 
In regard to 

STRICTURES RESULTING FROM GONORRHGEAL INFLAM- 
MATION. 

These are apparently the most numerous of all 
varieties of urethral stricture. It is not usually 
borne sufficiently in mind that strictures may exist 
for a very long period without producing any 
symptoms which attract attention. Symptoms of stric- 
tures occurring at a shorter or longer period, after an 
attack of gonorrhoea, lead to an examination, and if 
stricture is discovered to be persent the gonorrhceal 
accident is very likely to get the credit of it. The fact 



GONORRHOEA AND ITS SEQUELS. 43 1 

is that a gonorrhoea! inflammation usually causes im- 
mediate accessions of plastic material to previously stric- 
tured points, and thus calls attention to their presence 
and locality. It thus becomes quite impossible (with 
the knowledge of the various causes of stricture, inde- 
pendent of gonorrhoea) to form a just estimate of the 
number of cases of stricture due to gonorrhoea alone. 
All strictures appreciated as firm bands of contraction 
within a few weeks or months after an attack of gonor- 
rhoea may be safely thrown out of the estimate and at- 
tributed to previous trouble of some one of the varie- 
eties previously mentioned as capable of causing stric- 
ture. The contracted urethral orifice seldom causes 
trouble until after the occurrence of a gonorrhoea 
which, adding to the obstruction by new accretions of 
plastic matter, thus, infiltrating the tissues at this 
point, and, while often apparently not greatly diminished 
in calibre, are greatly lessened in resiliency, and thus 
produce the effect of greater contraction. 

SYMPTOMS AND DIAGNOSIS OF STRICTURE FOLLOWING 
GONORRHOEA. 

" Gleet" is the signal which nature hangs out to no- 
tify the patient and his surgeon that the urethra is 
strictured at some point. 

As the urine is propelled through the urethra, it im- 
pinges with more or less force upon any salient or con- 
tracted point. The column of fluid is arrested, and in 
proportion to the degree of arrest is the force of the 
blow upon the mucous surface at that point. Localized 
disturbances of the muscular action occur, preventing 
complete emptying of the urethra. More or less hy- 
peraemia necessarily ensues, and a condition is soon es- 
tablished, well adapted to prolong an existing gonor- 
hoea, or which, upon slight additional cause, such as 
venereal excitement, or even an unusually acrid condi- 
tion of the urine, may result in the origination of a mu- 
co-purulent, or a purulent secretion. We may hence 
affirm, as a most important axiom, that the slightest en- 
croachment upon the calibre of the urctJiral canal is suffi- 



432 GONORRHCEA AND ITS SEQUELS. 

cient to perpetuate a urethral discharge, or even, under 
favoring conditions, to establish it de novo without venereal 
contact. 

It is in this way that gonorrhoeas occuring a few 
hours after exposure are generated. It also explains 
the apparently unaccountable renewal of a urethral dis- 
discharge after excitement, in individuals who have had 
no gonorrhceal disease for years. 

And yet in some cases the urethra may be strictured 
at several points, and to a very considerable degree, 
without any perceptible purulent discharge. So that 
while gleet is an evidence of stricture, the absence of 
it does not prove that the urethra is free from impor- 
tant contractions. In other words, an amount of habit- 
ual friction of the mucous membrane of one urethra 
may be borne without marked irritation, which in an- 
other will soon set up inflammatory action. 

Frequent urination, a twisted and irregular stream, 
a dribbling at the close of the act, are all evidences of 
stricture at one or more points, and yet all may be ab- 
sent without proving the absence of stricture. 

All may be present and due to other Causes than 
stricture. Hence it becomes necessary to examine 
still further before a positive diagnosis can be made. 

The first step toward determining positively the 
presence or absence of stricture in a given case is made 
by the actual measurement of the normal dimensions or 
calibre of the urethra. To obtain a convenient test- 
measure for reference the so-called urethral scale is 
used. 

It is not necessary to enter into an elaborate argument, 
in order to prove that any and every subject which has 
an intrinsic value, should in publication be so treated as 
to render it intelligible in its essential points to scien- 
tific men in every part of the world. 

Recent vigorous efforts have been made to bring about 
an adoption of the metric system of weights and meas- 
ures by the medical profession of all countries. This 
suggests the practicability of a much-needed applica- 
tion of the same system to surgery, not alone to secure 
a more accurate measurement of anatomical proportions 



GONORRHCEA AND ITS SEQUELS. 433 

and surgical instruments and appliances, but through 
this, as a common and simple medium, to facilitate the 
harmonious and intelligible interchange of scientific facts 
and observations. It is especially in the department 
of genito-urinary surgery that such a reform measure 
is needed, as here the most delicate appreciation of 
anatomical proportions and deviations, and hence the 
most delicate and accurate adaptation of instruments, is 
required. The want of some one exact and easily ap- 
plied system of measurement of necessity depreciates, 
and often wholly negatives the scientific value of im- 
portant observations. A rapid survey of this matter, 
as it affects genito-urinary questions, will serve to em- 
phasize the foregoing statement. 

The systems of measurements and estimates of ure- 
thral instruments and urethral calibre, in Great Britain, 
on the European continent, and in America, have always 
been, and still are, notoriously at variance. In England, 
such measurements are nominally governed by a fixed 
scale, but this is readily seen to be without any scientific 
basis. The normal calibre of the urethra has been esti- 
mated and a fixed standard assumed, unsupported by rea- 
son, anatomy or experience. Instruments for catheter- 
ism, or dilatation of stricture, or other procedures, have 
been graded by sizes from 1 to 12, while the normal 
calibre has been fixed at from 8 to 1 1 of this scale. The 
advance from the lowest to the highest numbers is by 
a conventional and irregular progression. 

In the most recent work of Sir Henry Thompson, 
" Diseases of the Genito-Urinary Organs," London, 
1876, that eminent English authority says, on page 54: 
" The ordinary range of our numbers is from 1 to 12. 
In England we cannot be said to have a uniform scale : 
one maker makes one scale and another another ; and 
the Scotch scale differs by i£ from the English, so that 
the patient who takes No. 12 Scotch takes only io£ 
English." The English scale, accurately measured by 
millimetres in circumference, runs thus : 7 mm., 8 mm., 
9 mm., o mm., 11 mm., 12 mm., o mm., o mm., 15 mm., 
16 mm., 17 mm., 18 mm., 19 mm., 20 mm., o mm., 22 mm. 

Hence Sir Henry Thompson advises the rejection of 



434 GONORRHOEA AND ITS SEQUELS. 

this English scale altogether, and the adoption of the 
French scale, which he says begins at i millimetre in 
circumference and increases by i millimetre in circum- 
ference up to 30.* 

In America, the imperfect English scale, introduced 
largely through the influence of Sir Henry Thompson's 
earlier writings (" Thompson on Stricture of the Ure- 
thra," London, 1853, etc.), came into general employ- 
ment and is still much in use. 

The first authority to protest against it was Dr. 
Bumstead, in his work on Veneral Diseases, 1861, who 
there adopted and recommended the French scale, and 
to facilitate its use among those accustomed to the 
English scale, had the approximate English numbers 
stamped on the reverse of the scale. 

This was recommended under the impression, as also 
stated by Sir Henry Thompson, that the French Char- 
riere filiere scale increased in size by 1 millimetre cir- 
cumference (Bumstead on Venereal Diseases, second 
edition, p. 267). Dr. Gouley, in his work on the " Gen- 
ito-Urinary Organs," New York, 1873, p. 28, also pro- 
testing against the use of the English scale, presents a 
" metrical sound gauge" measuring by diameters instead 
of circumference. " This new gauge consists of 20 num- 
bers, the smallest 1 millimetre and the largest ioj- milli- 
metres in diameter, with a difference between each two 
numbers of -J mm. instead of \ mm., as in the French scale. 
On one side of my gauge is stamped the diameter of 
each aperture in millimetres, and on the reverse side 
was from J to 18, which very nearly correspond to the 
numbers of the English scale." The Gouley scale, as 
it came to be called, thus differed from the Charriere 
filiere scale adopted and recommended by Dr. Bumstead, 
1st, by computing sizes in diameters instead of circum- 
ference , 2d, by decreasing the number from 30 to 20 ; 
3d, by carrying them to 10J mm. in diameter. This mul- 
tiplied by 3-J shows an increase in range over the Char- 
riere filiere scale from 30 to 34. Upon the handles of 

* " Thompson on Diseases of the Urinary Organs," 1876, p. 54. 



GONORRHOEA AND ITS SEQUELS. 435, 

Dr. Gouley's sounds both the English number and the 
diameter were stamped. 

In 1874 Drs. Van Buren and Keyes, in their work on 
the Genito-Urinary Diseases with Syphilis, erected and 
recommended still another gauge, which they called 
" the American scale." Rejecting the English scale on 
account of inaccuracy, and the French because they 
considered the increase of its sizes unnecessarily grad- 
ual, involving a necessity for too many instruments, " a 
needless expense with no compensating advantage." 
The so-called American scale, beginning with \ mm., in- 
creases in diameter by \ mm., like the Gouley scale, up to 
ioj- mm., but making the sizes from 1 to 20. The num- 
bers of these sizes are stamped under them, while over 
them is stamped the number of millimetres diameter. 
On the reverse the sizes are marked with numbers ap- 
proximating the millimetres circumference of the French 
scale. For my own part I adopted the French metrical 
measurements at an early period. My first metallic 
bulbous sounds (made by Hernstein, 1861), were in 6 
sizes, increasing by 2 millimetres in circumference from 
18 to 30. By a gradually increasing appreciation of the 
necessity for more accurate measurement and a wider 
range, I had by 1870 increased the numbers to 26 mm. 
from 8 mm. fo 34 mm., sizes graded by 1 mm. in circum- 
ference ; and by 1874, to meet the requirements of prac- 
tice, I was obliged to increase the numbers to 40. Dur- 
ing the same year my urethra-metre was devised and 
presented to the profession. This instrument was so 
arranged that measurement of the urethral calibre could 
be accurately made, and by means of a screw at the 
handle, which governed the size of the dilating appa- 
ratus at the distal extremity, and also an indicator which 
moved on a dial at the handle of the instrument, thus 
registering accurately the circumference oi the dilating ap- 
paratus, and also of the urethra when expanded to a size 
corresponding with its calibre (see p. ). The adoption 
of measurement by circumference in this instrument was 
a necessity, if for no other reason because of lack of 
room to express fractions of diameter. It was also 



43 6 



GONORRHCEA AND ITS SEQUELS. 



adopted on account of supposed conformity with the 
Charriere filiere scale. In an examination of the matter 
this was found by the late Dr. Bumstead to be an error, 
and shortly before his death my attention was called by 
him to the fact that the Charriere filiere scale increased 
in sizes by \ mm. in diameter. So that while in supposed 
harmony with the standard French scale (then generally 
adopted all over Europe), the English and American 
measurements based upon it differed by \ mm. in every 
i mm. diameter. Dr. Bumstead, in his latest edition, for- 
mulated this error, showing that in practice it may be- 
come a matter of considerable practical importance, as 
will be seen by the following table : 



No. 



I. 

2. 

3- 
4- 
5- 

-6. 
7- 
8. 

9- 
10. 
11. 
12. 

13. 
14. 

15. 
16. 
17. 
18, 
19, 
20 



Diameter 


Circum- 


in 


ference in 


Millimetres. 


Millimetres. 


0.33 


I.03 


O.67 


2.09 


I. OO 


3.14 


1-33 


4.19 


I.67 


2.44 


2.00 


6.28 


2.33 


7-33 


2.67 


8.38 


3-00 


9.42 


3-33 


10 47 


3-67 


11.52 


4.00 


12-57 


4-33 


13.61 


4.67 


14.66 


5-oo 


15-71 


5-33 


16.76 


5.67 


17.80 


6.00 


18.85 


6-33 


19.90 


6.67 


20.94 



No. 



21 

22 
23 
24 
25 
26 
27 
28 
29 
30 
31 
32 

33 
34 
35 
36 

37 
38 
39 
40 



Diameter 
in 

Millimetres. 



7.00 

7-33 
7.67 
8.00 
8-33 
8.67 
9.00 

9-33 

9.67 

10.00 

io.33 
10.67 
11.00 

11-33 
11.67 
12.00 

12-33 
12.67 
13.00 
13-33 



Circum- 
ference in 
Millimetres. 



21.99 
23.04 

24.08 

25-13 
26.18 
27.23 
28.27 
29.32 

30.37 
31.42 
32.46 
33-51 
34.56 
35.6o 
36.65 
37.70 
38.75 
39.79 
40.84 
41.89 



Charriere filiere: Diam., 1; Circum., 3. 141 59. 

Fortunately the Scotch scale never emigrated to 
America, but without this we had practically five scales 
claiming to be authorities in estimating the urethral 
proportions: 1st, the old English scale, Thompson ; 2d, 
the French Charriere filiere, adopted by Bumstead with 



GONORRHOEA AND ITS SEQUELS. 437 

English attachment ; 3d, the Gouley scale, French dia- 
meters, with approximate English figures ; 4th, the 
American scale with approximate French figures ; 5th, 
the metric scale, increasing by 1 mm. in circumference 
and going 6 numbers higher than any other of absolute 
necessity, as I had demonstrated the frequent occur- 
rence of urethras the normal size of which was equal 
to 40, and even more. 

It will be readily seen that great embarrassment in 
appreciating descriptions of cases, when urethral meas- 
urements are considered, must of necessity arise, unless 
the profession throughout the world will take the time 
to acquire a familiarity with some one reliable mode of 
urethral measurement. 

Nothing is more common than for a surgeon to pub- 
lish a case stating that he had dilated the urethra up to r 
say, No. 21, omitting to state whether it was 21 French, 
21 English, 21 American, or Van Buren and Keyes, 21 
Gouley, or 21 mm. in circumference, and most likely if 
inquired of would say that it was the number marked 
on his sound, and he did not exactly know to which 
scale it belonged. Even if he were able to say, various 
readers would fail to appreciate any scale they were 
not in the habit of using. I would, then, urge the 
adoption of a uniform urethral scale graded by milli- 
metres in circumference, and for the following reasons : 

1st. That the metric system in all other matters is 
being rapidly adopted by the medical profession, for the 
sake of accuracy and uniformity throughout the world. 

2d. That it is already the standard in France, whose 
surgeons have done more to advance the science of ure- 
thral surgery than those of any other country, and that 
through their influence the continental surgeons have 
already adopted the metric system of urethral measure- 
ments in circumference. This system is in use by the 
best English surgeons and recommended by them, and 
it is also more generally adopted in America and in 
other parts of the world than any other. 

3d. That it meets all the necessary requirements and 
may be used to express any and all urethral sizes with- 
out the possibility of any misunderstanding or uncer- 



438 GONORRHOEA AND ITS SEQUELS. 

tainty. I would still further propose that all surgeons, 
as far as in them lies, should use their influence in eras- 
ing the numbers of all existing urethral instruments 
which are now marked with measurement figures other 
than those expressing measurements by millimetres in 
circumference, and having them remarked with the 
French figures in circumference. And finally, that all 
instruments hereafter ordered should be made and 
marked in conformity to the metric measurement by 
circumference. Dr. C. H. Thomas, of Philadelphia, in 
the Philadelphia Medical Times, June, 1879, in an article 
urging the necessity of a uniform scale of measurement 
for surgical instruments and apparatus, presented an 
ingenious contrivance of his own for ready and accurate 
measurement of instruments by millimetres in circum- 
ference. This is manufactured by Messrs. Gemrig & 
Sons, surgical instrument makers, No. 109 South Eighth 
Street, Philadelphia, who have generously offered to 
send this measureing scale gratuitously to any member 
of the medical profession desiring the same. 



GONORRHOEA AND ITS SEQUELS. 439 



LESSON LII. 

Urethral measurements — Necessity of the adoption of a uniform method — 
Note — Showing the want of some exact and common standard of 
measurement — Value of the urethrometre — Description of the instru- 
ment — Mode of using it — Proportionate relation between the size of 
the penis and the urethra — Table showing this relation — Verification 
of its correctness through actual measurements with the urethrometre 
of over one thousand cases — Difference in calibre between the bulbous 
urethra and the portion anterior — The bulbous sound — Usual locality 
of strictures — Stricture most frequent in the anterior portion of the 
canal — Statistics on this point — Solid steel sounds — Different varieties — 
Mode of introduction. 

The Urethral Scale. — This is graduated by the French 
millimetre from 1 m. in circumference to 40. On the 
opposite side are the numbers of the English scale. 
"The scale for grading the sizes of instruments has 
never been very accurately fixed, except in France."* 
The French scale increases by one millimetre in cir- 
cumference. This is a recognized standard scale in 
all countries at the present day, and the sizes of all 
other scales must be translated into this, in order to 
become intelligible in descriptions of cases. It is not 
rare to find urethras with normal calibre of 40. The en- 
tire set, from 8 m. to 40, is absolutely essential to every 
surgeon who desires to make complete and accurate 
urethral measurements. The stricture which will per- 
mit say 25 of this scale to pass without obstruction, will 
often hold distinctly and firmly upon a bulb measuring 
26 f. It is thus shown that the gradation of this scale is 
not too fine, and that no numbers can be dispensed 
with. 

For actual urethral measurement we have the Ure- 
thra-meter. — With this instrument an accurate measure- 
ment of the normal urethral calibre may be made, in 
any case, within the compass of the instrument, the 

* " Genito-urinary Diseases." Drs. Van Buren and Keyes, New York, 
1875, p. in. 



440 



GONORRHOEA AND ITS SEQUELS. 




O 'V_/^«i 



PT5 




«o a O ^ ' i 

o 



Oo* '^ 





G.TIEMANN KCO 



GONORRHOEA AND ITS SEQUELS. 



44I 



bulb of which can be made to expand from 2of. to 45L 
The dial, near the handle, indicates in millimetres the 
exact amount of expansion of the bulb. Introducing it 
closed (and covered with the rubber cap, which 
serves to protect both the instrument and the urethra) 
down to the bulbo-membranous junction, by means of 
the screw at the handle, the bulb expands up to the 
point of the sensation of fullness felt by the patient. 
The hand on the dial will then point to the figure rep- 
resenting the normal calibre of the canal under exami- 
nation. Strictures in the regions anterior to the bulb 
may also be accurately defined and measured by this 
instrument. When the bulb is suddenly arrested in 
withdrawal, the screw should be gradually turned un- 
til the bulb is permitted to pass. The position of the 
hand on the dial will then indicate the calibre of the 
stricture. It should, however, be borne in mind that 
when the urethra is very sensitive, spasmodic contrac- 
tion may simulate an organic stricture. It is, therefore, 
necessary to verify the results of this examination with 
the bulbous sound before deciding that true stricture 
exists. If the latter instrument defines a contraction at 
the same point, by measurement, and, when passed be- 
yond it, is distinctly held on return, the proof of organ- 
ic stricture is complete. When the urethral contrac- 
tions are below the calibre of the closed bulb, or when 
they are numerous and close together, the normal cali- 
bre of the canal may be assumed from the circumfer- 
ence of the flaccid penis. When the circumference is 
3 inches the urethra has a normal calibre of at least 30 f ; 
if 3i it will be 32 f; if 3i=33 f ; if 3f =3 6 ; if 4mches=38 ; 
if 4-I inches=40, or more 



Circumference Midway of the Penis. 



of PENIS. 

3 inches, or 75 mm. 

3^ " " 81 mm. 



3i " 

34 " 

4 

4i to 4i 



, 87 mm. 

93 mm. 

100 mm. 

105 to 112 mm. 



OF URETHRA. 

30 mm. 

32 mm. 

34 mm. 

36 mm. 

38 mm. 

40 mm. 



The correction of this proportionate relation has 



I 


millimetre. 


2 


millimetres. 


3 


( e 


4 


" 


5 


<< 


6 


«< 


7 


<( 


n 


" 




no difference 



442 GONORRHCEA AND ITS SEQUELS. 

been verified by the author's careful measurement in 
over one thousand consecutive cases, without meeting- 
with a single exception, in infancy, childhood, adult life, 
or old age 

In the measurements of one hundred cases of sup- 
posed normal urethrae, with the urethrometer, the 
measured difference between the bulbous urethra and 
the part anterior to it was — 

In 35 cases 

21 
18 

6 

2 

2 

2 

1 
13 

The average difference in the one hundred cases was 
2-3-8-5- millimetres, and the calibre of the ante-bulbous 
portion averaged 32.95. 

It may therefore be made use of with confidence as 
a basis in procedures : 

The Bulbous Sound. — This is intended solely for detect- 
ing the size, length, and locality of the urethral stric- 
tures. After ascertaining the normal calibre of the 
presenting urethra, a bulbous sound of corresponding 
size should be well oiled and presented at the meatus. 
If it passes in readily, this may be accepted as repre- 
senting the normal calibre. If only a smaller size will 
enter, the difference between this size and that indicat- 
ing the normal calibre will show the exact amount of 
contraction at this point. Figures on the handle indi- 
cate the exact size of the bulb ; frequent verification by 
means of the scale will aid in preventing errors of 
measurement. 

For convenience of description and study, strictures 
may be divided into two classes, viz., strictures of large 
calibre, and strictures of small calibre. 

Those permitting the passage of the urethrometer 
with cover, say 18 to 20, and all above that size, are 
classed as strictures of large calibre ; all those below 
that size are termed strictures of small calibre. 



GONORRHOEA AND ITS SEQUELS. 



443 



The usual locality of stricture : Out of 258 strictures, 
52 were in the first quarter inch of the urethra ; 63 in 
the following inch, viz., from, J to ij; 48 from ij to 2 J ; 




4 & 

Fig. 6. 



Fig. 9. The Author's 
Short-beaked Sound. 



48 from 2J to 3i ; 19 from 3jto 4J ; 14 from 4J to 5J; 8 
from 5 J to 6J ; 6 from 6J to 7J. 



444 GONORRHOEA AND ITS SEQUELS. 

In another series of 357 strictures only 5 were deeper 
than 5 inches. (See Otis on Strictures, pages 97 and 
317. Putnam's Sons, 1882.) In 446 strictures reported 
by Prof. Bevan, 89 per cent, or 399 strictures, were 
found anterior to 4-J inches. 

It was formerly claimed, that the great majority of 
urethral strictures is found in the vicinity of the bulbous- 
membranous junction, and various possible causes for 
their frequency in this locality were cited. 

By the above statement it will be seen that they oc- 
cur, as would naturally be expected, in greatest fre- 
quency where the inflammation begins the earliest, and 
rages the hottest, and gradually diminish in the deeper 
portions of the canal. 

Solid steel sounds of various curves are habitually 
used for purposes of diagnosis preparatory to the more 
thorough examination by means of the bulbous sound 
and the urethrometer. For examining the deep ure- 
thra it is better than either, as any bulbous instrument 
is certain to be more or less firmly held on introduction 
and retained by the anterior and posterior borders of 
the triangular ligament. There are three varieties, 
known as the Thompson or Van Buren curve, the 
Beinike curve, and the short beaked sound, the latter 
of which I most frequently use and recommend. 

Mode of Introduction. — Taking up the penis carefully so 
as partially to include the glans between the first two 
fingers and thumb, and taking up the sound lightly 
as you would a penholder ; introduce it well oiled 
pretty much by its own weight, turning it slowly if any 
halting occurs, in this way releasing its point from any 
obstructive folds of mucous membrane or engagement 
in a false passage, or natural sulcus. The larger the 
instrument used the less liable to arrest from such 
causes. Always begin with the largest instrument 
which the meatus will permit. In cases of contracted 
orifice a division may be necessary before any satisfac- 
tory introduction can be effected. 

As the sound is advanced gently draw up the penis 
on the sound, to meet it, keeping handle of the instru- 
ment well down as the abdomen is approached, thus 



GONORRHOEA AND ITS SEQUELS. 445 

avoiding arrest by the anterior border of the triangu- 
lar ligament ; then carry the handle slowly and well 
back until the instrument, following the deep urethral 
curve, passes well into the bladder, In cases of doubt 
as to a cause of arrest in the deep urethra, promptly 
pass your forefinger into the rectum. The obstruction 
may arise from a muscular fold just within the vesical 
orifice called a bar of the neck of the bladder, or it 
may be from recent or chronic enlargement of the pros- 
tate gland. In either case the finger will discover it and 
aid in the passage of the instrument. If spasmodic 
stricture is suspected, gentle pressure with the end of 
the sound against the face of it and continued for 5 or 
10 minutes will often overcome the spasm. The same 
measures may be used under profound anaesthesia. 
Even this will not always relax the spasm of certaim 
forms of urethrismus. Therefore, while there is still a 
doubt from any cause the matter should be held in 
abeyance until further effort under more favorable con- 
ditions shall result in a solution of the difficulty. 



446 GONORRHGEA AND ITS SEQUELAE. 



LESSON LIII. 

URETHROTOMY. 

Operations for the relief of stricture only productive of temporary bene- 
fit before the introduction of dilating urethrotomy — Standard calibre 
for the urethra formerly accepted as a basis for operative measures — 
Error of this view — The author's dilating urethrotome — Description of 
the instrument — Mode of using — Complete division of stricture neces- 
sary to its permanent cure — This only to be expected by dilating ure- 
throtomy — Early experiences with the dilating urethrotome — General 
summary of one thousand three hundred and thirty-one operations — 
Experience of Dr. Mastin, Professor Bevan, Professor Brown, Pro- 
fessor Pease, etc — Permanance of results — Clinical cases in illustra- 
tion — Efficacy and safety of dilating urethrotomy demonstrated by the 
experience of various competent surgeons — Similar results within the 
reach of any intelligent and careful surgeon — The author's experience 
in nearly one thousand operations. 

Operations for the relief of stricture of the male ure 
thra by dilatation, divulsion or incision had been in use 
from time immemorial, but, according to the teach- 
ing's of surgical authorities throughout the world, 
strictures were not absolutely cured by any one of these 
methods. All the numerous instruments and proced- 
ures which had been recommended and practiced for 
the treatment of urethral stricture were acknowledged 
to be inadequate to its radical cure ; in other words, 
were unable to effect a removal of stricture so complete 
as no longer to require subsequent treatment by the 
occasional passage of bougies or sounds. 

The operation of dilating urethrotomy, literally a 
dilatation of strictures up to the normal calibre of the 
urethra, and then thoroughly dividing — sundering — 
them at some one point, was first proposed by me some 
ten years since. 

In order to effect these objects with any degree of cer- 
tainty, it becomes necessary, in the first place, to ascer- 
tain with precision the exact normal calibre of the 
urethra in which the strictures are located. 

At the time referred to a standard calibre for the human 



GONORRHOEA AND ITS SEQUELS. 



447 



male urethra was assumed by authorities, and accepted 
by the profession at large, as a basis for operative pro- 
ceedures. This had been fixed at 8 or 9 of the English 
scale (corresponding to lines in circumference), and 21 of 
the French (representing millimetres in circumference). 

It was claimed that when a presenting urethra, the sub- 
ject of stricture, was by any means brought up to 8 or 9 
of the English scale (among surgeons who followed the 
teachings of the English school), or 21 of the French scale 
(for those who preferred the French authorities), the 
urethra could no longer be considered as strictured, and 
that further active treatment was unnecessary. The oc- 
casional use of sounds or bougies was, however, to be 
continued indefinitely. 

My dilating urethrotome, first presented to the pro- 




Fig. 10. The Author's Dilating Urethrotome. 

fession in 1871, was constructed for the complete divi- 
sion — the absolute sundering, of strictures, on a basis of 
exact knowledge of the normal calibre of the presenting 
urethra, and of the location and degree of stricture. 
This instrument consists of a pair of steel shafts (A and 
B) connected together with short pivotal bars, on the 
plan of the ordinary parallel ruler — as shown above in 
the expanded instrument. 

Its expansion and contraction are effected by means 
of a screw which traverses the handle connected with 
the lower shaft, and is moved by the finger-button C. 
This screw acts against the upper bar of the instrument 
as a fixed point, and on being turned moves the lower 
bar, dilating or contracting the size of the instrument. 
To the screw is attached an indicator, which is thus 
made to traverse a dial placed upon the upper bar, 
which registers exactly in millimetres the degree of 



448 GONORRHOEA AND ITS SEQUELS. 

separation of the bars, and thus the amount of dilata- 
tion which is being effected in any given case. 

Up to this point the instrument is simply a dilator or 
a divulsor, and may be thus used by introducing it 
closed into the urethra until its distal extremity is be- 
yond the ascertained point of stricture ; then, turning 
the screw, the instrument is expanded, dilating the 
ure up to the previously -determined normal size of 
the urethra. The upper bar of the instrument is tra- 
versed by a steel wire, at the extremity of which is a 
thin blade, not exceeding two millimetres in breadth, 
and when in place is concealed in a deep slot at the end 
of the upper bar. Now, by means of its handle the ure- 
throtome is drawn out of its concealment and made to 
traverse the stricture (firmly fixed and made thin by the 
previous dilatation), dividing it quickly and completely. 

After an experience in over fifty operations, in 1873, 
I called public attention to the results of complete divi- 
sion of urethral stricture by dilating urethrotomy in six 
cases. A careful re-examination of these cases, three at 
one year from the date of operation, two at six months, 
and one at five months, showed entire freedom from 
stricture, although in the interval no instrument of any 
description had been passed through the urethra in 
either case. 

The apparent radical cure of the strictures through 
complete division, and simple maintenance of the normal 
calibre of the urethra until the wounds of operation had 
healed, without subsequent passage of sounds or bou- 
gies, seemed to warrant the expectation of similar good 
results in other cases similarly treated. After an ex- 
perience with this method of over twelve years, it may 
now, I think, be safely claimed that this expectation has 
been amply met by the results given to the profession 
during this period. 

A general summary of 1331 operations made in ac- 
cordance with the principles above enumerated, may be 
found recorded in my volume on stricture of the male 
urethra, published by Messrs. Putnam's Sons, New 
York, and by Smith, Elder & Co., of London, p. 279. 

This covered my own experience in 635 operations; 



GONORRHCEA AND ITS SEQUELS. 449 

that of Dr. C. H. Mastin, LL.D, of Mobile, Ala., 296; 
Dr. Thomas R. Brown, Professor of Surgery in the 
College of Physicians and Surgeons, Baltimore, 300 ; 
Dr. R. W. Pease, Professor of Surgery in the Univer- 
sity of Syracuse, N. Y., 100; total, 1331. 

Since that report Professor Bevan, of the College of 
Physicians and Surgeons in Baltimore, has reported 300 
operations ; Dr. Eldridge, Surgeon-in-Chief of the Gen- 
eral Hospital at Yokohama, Japan, 100 ; Dr. J. L. Little, 
Professor of Clinical Surgery in the University of New 
York, 30 ; Dr. E. L. R. Thompson, of New Haven, Ct., 
211; my own additional operations, 325; making a 
grand total of 2297 operations without a death or per- 
manent disability of any sort. There have been re-ex- 
aminations reported at various dates subsequent to oper- 
ation, with the following results : Dr. Bevan, of Balti- 
more, out of his 200 tabulated cases, reports thirty re- 
examinations at periods varying from four and a half 
months to two years. Recontractions of stricture were 
found in but two cases. 

Dr. Mastin, of Mobile, reports twelve re-examinations 
at from four months to two and a half years, with re- 
contraction in three cases. Professor Pease, of Syra- 
cuse, reports that out of his first series of forty-five 
cases (operated on from 1875 to 1877) m twenty-one re- 
examinations at dates between four months and two 
years — thirteen of which were over one year — no re- 
contractions had taken place (see Otis on Stricture, 
p. 262). 

Of his subsequent experience in 296 operations under 
date of July 21st, 1881, he writes as follows: " The 
whole number of cases in my private practice of which 
I have a record, not published, is 273, comprising 395 
strictures. Of this number forty-seven were deep, or 
between six and a quarter and seven and a quarter 
inches. Out of this series of 273 cases eighty have been 
re-examined at from six months to four years from the 
date of operation. Out of this number of re-examina- 
tions fifty-nine gave perfect results, twenty cases had 
recontraction in one or more strictures, upon twelve of 
whom re-operations were made, and subsequently dis- 



450 G0N0RRHCEA AND ITS SEQUELS. 

missed cured ; two have drifted away, and six are await- 
ing a favorable time for re-operation. Urethral fever 
followed in nine cases, in three very severe. All re- 
covered, however, with no bad results. In three of the 
deep operations severe haemorrhage followed, control- 
led by the perineal crutch. In fourteen cases there was 
curvature of the penis, lasting from one to fifteen 
months. 

Dr. Mastin, in answer to my request for his latest ex- 
perience to be incorporated in a paper before the Sur- 
gical Section of the International Medical Congress 
held in London, August, 1881, writes under date of 
July2ist, 1881 : 

" I have thought it would serve at this very late date 
if I would drop you a line, and in it permit you to use 
my unqualified approval of your method of the radical 
cure of stricture. It would be useless for me to add 
new cases in which I have done the operation, because 
it is not increased numbers, but rather a few cases, of 
long duration which go to prove the value of the method. 
Five hundred cases done in the past six months, would 
prove less than five cases done six years ago. It is the 
permanency of the cure, and not the number of operations 
done which will go to prove the radical results. To 
this end I have thought it best to take up the list of 
thirty cases, already published in the first edition of 
your work on stricture (see page 248 et seq.), and give 
you the result of recent examinations. 

Case I. — Operated upon by dilating urethrotomy in 
December, 1 874, six years and six months ago. This case 
has been under constant observation, and after repeated 
examinations I have been unable to find the least recon- 
traction. He has married since the operation, and has had 
no trouble whatever with his genito-urinary functions. 
He has not used a sound to keep patent his canal, and I 
find his urethra up to its normal calibre. I consider his 
cure perfect and believe that six years is fully long 
enough to show whether a return is liable. He has 
been engaged all the time at hard work, being an en- 
graver and machinist. 

Case II. — Operated upon in February, 1875. This 



GONORRHCEA AND ITS SEQUELAE. 45 I 

man passes my office four or five times every day, and, 
as a consequence, I have had ample opportunity to have 
him under close and continued observation. Repeated 
examinations in the past six years have shown there has 
been no recontraction ; and on more than one occasion 
I have put a No. 40 m.f. sound easily into the bladder. 
It will be remembered that I cut him to 38 m. f., but 
afterwards I carried the sound up to 40 m.f., and find 
that they can be passed without force to that size now. 

The prostatic irritation which remained for some 
months after the operation has gradually subsided, and 
at this date he enjoys perfect health. Being unmarried 
he has led a life of some irregularity, but fortunately 
has not contracted a discharge, nor has he been in- 
temperate in drinking. 

Case III. — Operated upon in September, 1875, 35 m - *•> 
near six years ago. Two months ago he had no re- 
contraction and remains perfectly well. Neither of 
these cases have used a sound to keep the urethra open ; 
nor have they complained of any urethral trouble. 

Case IV. Has died from heart trouble, but from the 
date of operation in November, 1875, to 1878, he had no 
return, and examination showed an urethra without any 
lessening of calibre. 

Case V. — Was not considered a fully tested case, and 
doubt was expressed as to whether the operation would 
prove a success as the urethra was not opened to its 
normal calibre, and a considerable amount of discharge 
kept up. The operation was done in December, 1870. 
In the fall of 1880 he still had a degree of urethral 
irritation and occasionally some discharge, but the 
patency of canal remains up to 31 m.f. Although I do 
not consider this case cured of his stricture, still I do 
consider that his contraction has been prevented from 
growing worse, by reason of the character of operation 
which was performed. It is furthermore worthy of 
notice to state that he has not resorted to the use of 
sounds to keep the canal open. 

Case VI. — Operated upon in November, 1875. Has 
since resided in New Orleans, and I have had no oppor- 
tunity to make a personal examination of his case, but 



452 GONORRHOEA AND ITS SEQUELS. 

hear from him that he is perfectly well and has had no 
diminution in the size of his stream of urine. 

Case VII. — Operated upon July, 1876, five years ago. 
Has married since, and is the father of three children ; 
an examination in February, 1880, showed his urethra 
open to 36 mi., and no evidence of the least trouble. 
A letter from him contains this sentence : " Another 
bouncing boy ; 1 am perfectly well, and you can score 
me down among the list of radical cures. 

Case VIII. — Operated upon December, 1876. This 
case examined a year ago shows the same condition 
that he was in when discharged ; no recontraction, and 
general health perfectly good. 

Case IX. — The history of this case as given in your 
book, page 252, is interesting and worthy of notice. He 
was seen some two months ago and remains perfectly 
well. From the varied kinds and number of operations 
performed upon him ; his frequent and rapid relapses 
from September, 1869, to November, 1875, will show 
the permanent value of dilating urethrotony over any 
other method. I consider this a test case. 

Case X. — Operated upon November 19th, 1875. He 
continued perfectly well, and had no evidence of recon- 
traction after his death, which occurred some two years 
since. He died from "phthisis." 

Case XL — Operated upon in February, 1877. Was 
examined in 1879; no recontraction found. Have not 
seen him since 1879, but a recent letter informs me that 
he is perfectly well, and has had no trouble in urinating. 
No sounds have been used to keep open the urethra. 

Case XII. — Operated upon in 1875 ; not given in your 
book. Urethra opened to 38 m. f. A physician who has 
had some considerable experience in treating these cases ; 
reports himself cured and from his own examinations 
says he has no recontraction. 

Other cases could be given equally convincing, but as 
they are of more recent date I prefer to take old opera- 
tions as more reliable, and better calculated to prove the 
value of your operation. As you will see, I have written 
in very great haste, as but little time remains for this to 
reach you before the meeting of the Congress." 



GONORRHOEA AND ITS SEQUELS. 453 

Dr. E. L. R. Thompson of New Haven, Conn., reports 
the results in his 211 cases as follows, viz. : 

In 174 cases re-examined at varying periods after 
operation there was no recontraction. 

Twenty-two cases which were not re-examined were 
perfectly well when last heard from. 

In 8 cases there was perfect relief for a length of time, 
then a return of symptoms, when on re-examination re- 
contraction was found to have occurred. 

In three cases which were still under treatment, most 
of the symptoms were relieved, some still remaining. 

There had been only partial relief in four cases. 

Of my own first 100 tabulated cases, out of 36 re-exam- 
inations with the bulbous sound, 31 were found free from 
stricture, 12 over six months, 3 over one year, 1 two 
and a half years, and 1 three years after operation (Otis 
on Stricture, p. 100). 

In my second series of 136 tabulated cases (ibid., p. 324), 
out of 82 re-examined, 67 cases were found entirely free 
from stricture. 

3 cases 6 years and six months after operation. 

2 " 5 years and over. 

3 " 4 " " 
10 " 3 " " 

j a ^ ic a 

20 " i year " 

10 " 6 months and over, (ibid., p. 319). 

In the second edition of my work (prefatory re- 
marks), two cases were cited, re-examined in May, 1880, 
thus over eight years from the date of operation, and 
found to be free from every trace of stricture, the ure- 
thra being free to the passage of 30. bulbous sound in 
one case, and 32. in the other. In the first case five stric- 
tures were originally present, the smallest of a calibre 
of 22 f. In the second case there were also five strictures 
operated on, the smallest 16 f. 

In addition to these cases was one, a surgeon, operated 
on March 6th, 1875, for four strictures defined by a 24 
bulb in a urethra of normal calibre 36 f. 

Re-examined May, 1880, and found free from stric- 
ture by the easy passage of 36. bulbous sound, six years 



454 GONORRHCEA AND ITS SEQUELS. , 

after operation, and no instrument introduced during 
the interval. 

Again, in 1881, 1 had an opportunity of re-examining 
two other cases, one (the first), whose strictures, four in 
number, were divided from 27 f. to the normal urethral 
calibre (in this case), viz., 36 f. The second, where six 
strictures were originally present, ranging from 24. to 30. 
in a urethra of 38 f. and when an acute inflammatory 
discharge had been present for over four months. In 
each of these cases a radical cure was demonstrated, 
the former seven years after operation and the latter 
over eight years. In May, 1883, I examined a case 
operated on in May, 1871 — two strictures — and another 
operated on in June, 1874, in which not the least recon- 
traction had taken place, thus showing a permanence of 
results with, in the first place, thirteen years, in the 
second nine years' interval between operation and re- 
examination. 

Dr. Stuart Eldridge, (formerly Professor of Anatomy 
in the Georgetown University, U. S. A., and now chief 
surgeon of the general hospital at Yokohama, Japan), 
reported a case in the New York Medical Journal of 
May, 1879*, where from long-standing disease the ure- 
thra was contracted to a filiform size, throughout the 
ante-bulbous portion. The operation of M. Maison- 
neuve was first performed, and this immediately fol- 
lowed by the introduction of my dilating urethrotome, 
and the urethra raised through its use to the supposed 
original calibre of the canal. The patient made a good 
recovery, and on a post-mortem examination of the case, 
made two and a half years after the operation, the ure- 
thra was found to be entirely free from stricture. In 
his description of the post-mortem appearances, Dr. 
Eldridge says, "The most careful, examination of the 
specimen failed to discover the slightest pathological 
constriction at any point, while neither thickening nor 
induration could be discovered by the most pains-taking 
search." This statement was fully verified through the 

* Reprinted with wood-cut in the appendix to 2d edition of " Otis on 
Stricture of the Male Urethra." Putnam's Sons, New York, 1880. 



GONORRHCEA AND ITS SEQUELAE. 455 

specimen which was forwarded to me by Dr. Eldridge, 
and presented to the New York Pathological Society 
in the latter part of the year 1879 ( see Appendix, " Otis 
on Stricture," Putnam's Sons, 1880). 

When it is considered that the operations reported in 
the foregoing pages have occurred in the practice of but 
six surgeons, and that many hospitals in America and 
nearly, if not quite, every hospital in the City of New 
York, is supplied with instruments for the performance 
of dilating urethrotomy, and that this operation there is 
no longer a novelty ; when, also, it is considered that the 
operation is practiced by many surgeons in private prac- 
tice in America and in Europe, it will be understood that 
the record of operations, considerably exceeding two 
thousand, might have been greatly increased, and have 
still further confirmed the statements as to the safety and 
utility of the operation of dilating urethrotomy. The 
fact that when properly performed its benefits are so 
prompt and pronounced, and that it is so readily done, 
has doubtless induced many surgeons to venture upon 
it without sufficient knowledge of the operation or with- 
out sufficient surgical experience, or without the proper 
instruments. For these, and often for other reasons, the 
strictures have not, in many cases, been thoroughly di- 
vided or properly cared for subsequently, and the 
results have, in many instances, been imperfect. I do 
not, however, hesitate to say that with the (my) well- 
made, short, straight, dilating urethrotome, used with 
the knowledge, skill, and judgment, necessary to the 
performance of any operation for the relief of difficul- 
ties of like gravity, and followed by judicious treatment 
until the healing has taken place, any good surgeon 
may attain results similar to those which I have cited. 
When the operation is confined to the limits of the ante- 
bulbous portion of the urethra, where alone it should be 
employed (and where, fortunately, by far the greatest 
proportion of strictures will be found), it may be said, 
practically, to have been demonstrated to be a safe oper- 
ation. Not a death has yet, as far as my knowledge ex- 
tends been fairly recorded against it, and surgical acci- 
dents may be justly claimed to be fewer than in any 



456 GONORRHOEA AND ITS SEQUELAE. 

other operation, of like importance, in the whole range 
of operative surgery. 

In my own experience of over nine hundred oper- 
ations, not only have I never had a death or a permanent 
disability of any sort, but I can say to-day that I have 
never performed the operation as advised in the foregoing 
pages, either to my own regret or without marked or ac- 
knowledged benefit to the person operated on. 



GONORRHOEA AND ITS SEQUELS. 457 



LESSON LIV. 

Consideration of the operation of dilating urethrotomy continued — Im- 
portant in proportion to the degree of difficulty presenting — Subjects of 
disease of bladder and kidneys most liable to suffer from any opera- 
tive procedure — Dilating urethrotomy less grave than any other mode 
of relief — Strictures in the anterior portion of the urethra less liable to 
cause trouble from operation than those seated more deeply — Greatest 
proportion of strictures shown to be located in the anterior portion of 
the urethra — Strictures of large calibre most frequently the cause of 
trouble — Easy and safe relief to such strictures by dilating urethrotomy — 
Details of operation in cases of strictures of large calibre — Strictures at 
or near the meatus urinarius — Mode of operation — Strictures more 
deeply seated — Mode of operation by means of the dilating urethro- 
tome. 

The operation of dilating urethrotomy, like any other 
legitimate surgical procedure, is important in propor- 
tion to the amount of difficulty present and the grav- 
ity of the troubles complicating it. In subjects affected 
with grave disease of the bladder and kidneys, any 
operation on the urinary apparatus is more or less haz- 
ardous. Dilating urethrotomy, however, has been fully 
demonstrated to be the least so, as in its performance 
the least degree of injury is inflicted necessary to divi- 
sion of stricture, and besides, in the very greatest ma- 
jority of cases, it is not necessary to pass any instrument 
through the deep urethra or beyond the locality of the 
stricture. 

In direct opposition to the statements of authorities 
who have not examined the urethra by means of the 
urethrometer, but who have made up their statistics 
from post-mortem inspection, it will be found that by 
far the greatest proportion of strictures calling for opera- 
tion or any treatment, are situated in the penile urethra, 
and will be found in less frequency the farther we re- 
cede from the meatus urinarius. In point of fact, 
being the result of inflammatory action, stricture will 
be found most frequent in the anterior portion of the 
urethra, where inflammations are most frequent and 
severe. 



458 GONORRHOEA AND ITS SEQUELS. 

In my experience, the greatest number of strictures 
which call for operative measures are the so-called " stric- 
tures of large calibre," which produce and prolong ure- 
thral discharges, sometimes causing reflex disturbances 
which result in recurring epididymitis, spasmodic stric- 
ture and retention of urine, frequent micturition, pain- 
less or otherwise, catarrh of the bladder, neuralgias, 
abdominal, dorsal, or sciatic, and a legion of possible 
troubles, mental and physical, which can only be reached 
efficiently by removal of the strictures. 

For all such cases dilating urethrotomy presents a 
promise of speedy and permanent relief, and as a rule, 
when properly performed, resulting in a radical cure 
of the stricture. 

The treatment of stricture by dilatation, that is to 
say, through the introduction of gum-elastic bougies, 
whalebone, etc., of various kinds and sizes, and steel 
sounds, long in use and approved by all authorities, has 
always been open to the objection that the results of 
such treatment, when well borne, were but temporary, 
and that once required, such dilatation was necessary 
throughout the life-time of the patient. There has 
never been any question but that dilatation of stricture 
was invaluable for temporary relief, especially in cases 
where urination was interfered with, or where the cir- 
cumstances were such, from any cause, that time could 
not be spared for more radical measures. In point of 
fact, it is only within a few years that any causes short 
of interference with the act of urination were consid- 
ered to warrant other operative measures than through 
gradual dilatation. It was in 1862 that I first demon- 
strated to the profession the capacity of stricture of 
long calibre to perpetuate, even to originate a urethral 
discharge, and scarcely a year later, the influence of 
such stricture in causing reflex irritation and neural- 
gias,* and spasmodic stricture. The possible influence 
of strictures of large calibre has now come to be gen- 

* Paper On Reflex Irritation Throughout the Genito- Urinary Tract, 
resulting from Contraction of the Urethra at or Near the Meatus Urina- 
rius — Congenital or Acquired. Read before the N. Y. Academy of 
Medicine, Feb. 19, 1874. 



GONORRHOEA AND ITS SEQUELS. 459 

erally accepted, and the propriety of operating on such 
strictures, with the view of effecting their permanent re- 
moval, it may be said is now well established. 

The chief cause calling for treatment of strictures of 
large calibre is a persistent or a persistently recurring 
urethral discharge. If this is at all inflammatory, it is 
desirable to defer operation until the discharge has, by 
rest and sedative injections, come to be painless, or bet- 
ter, until it has for the time entirely ceased. Cases will 
occasionally present where such discharge is rebellious 
to all treatment, and continues profuse and more or 
less painful. In such cases, the inflammatory action 
usually interferes with the rapidity and completeness of 
the recovery. 



DETAILS OF OPERATION ON STRICTURES OF LARGE 

CALIBRE. 

Arrangements should in all cases be made for the 
patient to remain in bed from forty-eight hours to a 
week after the operation. Administration of ether 
facilitates the accomplishment of the different neces- 
sary procedures. With proper arrangement of all pre- 
liminary details (such as measuring, and locating, and 
noting down the different strictured points, arranging 
instruments, etc.), the operation may usually be done 
under the first effect of ether. 1st. After having ascer- 
tained the normal urethral calibre in a given case, note 
carefully, in writing, the different points of stricture, the 
calibre and extent. 2d. If the urethral orifice is not of 
the full size of the normal urethra, as previously esti- 
mated, operative measures should commence by a restor- 
ation of the canal at this point. Thus, holding the penis 
tightly with the thumb and first finger of one hand, in- 
troduce a well-oiled, straight, blunt bistoury for a full 
inch, then testing the density of the tissues (which may 
vary from slight thickening to dense cicatricial struo 
ture) by drawing out the blade under gentle, steady 
pressure, again introduce, and divide to a point which 
appears to be sufficient to enlarge the canal to the pre- 
determined proper size. 



460 GONORRHOEA AND ITS SEQUELS. 

Now, with a bulbous sound corresponding to this, 
test the size attained. If the bulb passes in and out with 
perfect freedom, the operation is accomplished. If, how- 
ever, there is the slightest hitch, either in entrance or 
withdrawal, the bistoury should be re-introduced, and 
with a forefinger supporting the under aspect of the 
glans, and make repeated cuts with exceeding care 
until cicatricial tissue is no longer felt, and the bulb 
passes in and out without hindrance. In cases when 
the meatus is situated very low, almost looking down- 
wards (as it does in some cases), this operation is often 
a most difficult and delicate one, that is, to get sufficient 
room without making an artificial hypospadias. This 
of course must be avoided. It is always a misfortune 
to be obliged to incise the canal superiorly at this 
point, not only because recontraction is much more 
likely to occur, but because the certainty of getting 
through the cicatricial tissue is much less, and sub- 
sequent induration and recontraction is more likely to 
follow. In cutting inferiorly, too, the pocket of the 
fossa navicularis is obliterated, a very important point 
in cases of gleety discharge, as it may be held here, 
notwithstanding the superior incision, and then by still 
holding the discharge, still fail to afford the relief an- 
ticipated from enlarging the orifice. 

Where division of the orifice is alone required, respect 
should still be had to the possibilities of troublesome 
haemorrhage resulting. A little pressure between the 
thumb and fingers will commonly suffice to arrest imme- 
diately following operation. Again, haemorrhage is quite 
free and persistent, or will come on soon after operation 
from movement or urination. A couple of narrow paste- 
board slips may be laid, one on each side of the penis, and 
pressure on these made by two or three turns of band- 
age, the end of which may be split into six tails, brought 
around and tied with much or little pressure, as re- 
quired. I always insist upon every patient, whose 
urethral orifice I divide, securing a nurse or intelli- 
gent friend to watch with him for the first two or three 
nights after the operation. The act of erection occur- 
ing during sleep sometimes causes haemorrhage to 



GONORRHOEA AND ITS SEQUELS. 461 

recur, and considerable blood may be lost before the 
patient awakes. I have seen fully half a pint lost in 
this way within an hour or two. My friend, Professor 
Thomas M. Markoe, related to me an instance, where 
many years ago he was called to see a man who was 
said to be bleeding from the penis ; the man died just 
before Professor Markoe arrived. On examination it 
was found that he had bled to death from a division of 
the meatus urinarius. This was several years before 
anything was understood about normal urethral cali- 
bra, but it is noteworthy, as showing that in certain 
cases of hemorrhagic diathesis, serious haemorrhages 
may occur from so slight an operation as a division of 
a contracted urethral orifice. From the fact that 
occasionally tendency to troublesome haemorrhage does 
exist, and we cannot tell beforehand which cases will 
behave in this way ; therefore, all cases should be cared 
for as if it were a certainty that haemorrhage would 
take place and this care should not be relaxed until 
three days from the date of operation. The after- 
treatment consists simply in the introduction of a 
full sized bulb daily or every other day, until heal- 
ing is complete. If healing is sluggish, it may be stim- 
ulated by a little carbolated lotion applied through a 
film of absorbent cotton. If a diphtheritic pellicle 
comes on, as occasionally will occur, a powder com- 
posed of equal parts of non-saccharated pepsin (Bou- 
dault's), and sub-carbonate of bismuth may be sprinkled 
into the opened orifice, three or four times a day. 

In regard to strictures situated beyond the fossa 
navicularis, or the first inch of the urethra, an entirely 
different procedure becomes necessary. All stric- 
tures beyond this point should be incised on the super- 
ior surface of the canal and directly in the median line, 
The incision should be made to include every fibre of 
stricture tissue if permanence in results is anticipated. 
The advantages of the superior incision are chiefly two : 
First, the tissues in this location are less vascular above, 
especially when approaching the bulbous portion, and 
hence the liability of troublesome haemorrhage is 
lessened. Secondly, the certainty of dividing through 



462 GONORRHCEA AND ITS SEQUELAE. 

the entire thickness of the stricture without unneces- 
sary risk is greater. When the stricture tissue is quite 
thick and approaches the surface of the penis the in- 
cision necessary to divide it completely on the infe- 
rior wall, would sometimes not only extend into the cellu- 
lar tissue outside of the urethra and thus perhaps lead to 
formation of abscess, but might go quite through the in- 
tegument and result in a troublesome fistula. Any oper- 
erative measure which would result in complete division 
of such stricture would make it necessary to put the 
integument into a state of extreme tension and thus 
make it so thin that it would be easily cut through. 
In order to divide any stricture with certainty and 
completeness it must first be put on the stretch so as to 
fix and thin the stricture tissue and thus easily sunder 
it. This is best accomplished by means of the dilating 
urethrotome. Having then divided the stricture or 
contraction at the urethral orifice after the manner 
recommended, examine as to the locality and calibre of 
all deeper strictures as far back as the bulbo-membran- 
ous junction, which is usually not to exceed five and a 
half or six inches from the urethral orifice. Having 
located any presenting strictures, take the dilating 
urethrotome well oiled and the blade in its conceal- 
ment at the extremity. Place upon the shaft a thin 
rubber band (once or twice doubled to keep it in place) 
at just the distance from the heel of the blade which 
corresponds to the previously measured distance 
from the extreme posterior border of the deepest 
stricture. Then, the patient lying on his back on a 
lounge or bed, and the surgeon standing by the 
side most convenient, introduce the shaft, again well 
oiled, into the urethra until the rubber band is one 
half of its breadth well in the meatus and the dial face 
of the urethrotome looking squarely upwards. Let 
the penis now be steadied by an assistant, so that the 
incision shall be directly in the median line. 



GONORRHOEA AND ITS SEQUELS. 463 



LESSON LV. 

Description of the operation of dilating urethrotomy continued — Small 
amount of haemorrhage usually resulting — Method of arresting haem- 
orrhage — The cold-water coil — Method of arresting haemorrhage from 
the deep urethra — The perineal crutch — Close strictures in the deep 
urethra best treated by external perineal urethrotomy — Great majority 
of strictures in the ante-bulbous portion of the urethra — After-treat- 
ment in operations by dilating urethrotomy — Treatment of strictures 
of small calibre — Urethral fever — To prevent this — Necessity of great 
care in cases of long-standing urethral trouble and in elderly persons — 
Preparatory treatment — Other accidents occasionally following dilat- 
ing urethrotomy — Accidents most commonly the result of want of 
proper care subsequent to operation. 

The next step in the operation is to turn the screw 
at the handle gradually, as indicated by the hand 
on the dial, so that it marks two millimetres (the 
blade being just two millimetres in breadth), be- 
yond the previously ascertained normal calibre of the 
urethra, and draw the blade completely through the 
breadth of the posterior stricture, and push it back 
again into its place of concealment. Turn the screw 
button still further, a millimetre or so, and if no sense 
of resistance is felt, the stricture is probably divided. 
If resistance is still felt, turn up the screw so as to indi- 
cate one to two millimetres more, and again test, and so 
on until resistance from stricture tissue is not recog- 
nizable. If there are more strictures interiorly apply 
the blade in the same way to each if they are an inch apart, 
and there be no lessening of the normal calibre between 
them. If, however, they are nearer together than an inch, 
or there is even slight contraction of the canal in the in- 
terspace, draw the blade through all at once, and push it 
back as before, and test by turning the screw as previ- 
ously described. If the strictures are so numerous or so 
dense that dilatation is difficult, remember that the in- 
strument is not intended as a divulsor, but only to put 
the strictures on the stretch sufficiently to fix and thin 
them, but without damage to the instrument. Therefore, 
when dilatation is in this way hindered, pass the blade 



464 GONORRHOEA AND ITS SEQUELS. 

through the strictures and turn up farther. If again 
unduly resisted, repeat this proceedure until the hand 
on the dial indicates a dilatation fully two millimetres 
above the previously estimated, or ascertained normal 
calibre of the canal. In such numerous and resistant 
strictures they are likely to be of unusual thickness, and 
hence the incisions must be correspondingly free. After 
division, turn down the screw button until the hand on 
the dial indicates that the instrument is half closed, and 
withdraw, in this way preventing any engagement of 
tissue between the bars. 

The withdrawal of the dilating urethrotome is usually 
accompanied, or immediately followed by a gush of 
blood, perhaps three or four drachms, and then slight 
oozing for some little time after ; rarely, however, re- 
quiring especial measures, except winding the penis 
snugly in a folded towel, or a three-inch bandage. 
If considered desirable, the penis may be drawn up 
and pasteboard splints applied conveniently as far 
back at three and one-half inches, in the same way 
as recommended in haemorrhage from the meatus, 
or, in addition, an open end, soft or gum-elastic catheter 
may be introduced into the urethra to a point just be- 
yond the posterior cut portion, before the bandage is 
applied. A straight tube is better than a solid bougie, 
as it permits urination without removal. The cold- 
water coil is also of value in arresting slight haemorr- 
hage.* 

*The Cold- Water Coil in Inflammation of the External Male Genital Ap- 
paratus, and as an Antiphlogistic after operations on the Penis* — The ap- 
paratus which I have designated the " Cold-Water Coil" is formed of a 
line of the small-sized India-rubber tubing of one-sixteenth of an inch 
calibre, and six or seven yards in length. At the middle portion this 
tubing is coiled upon itself, so that, by half a dozen turns or more, it 
presents sufficient capacity to loosely encircle the entire penis or scrotum. 

This coil, with the length of tubing proceeding from it, forms an appara- 
tus through which, on placing one extremity of the tubing in a bowl or 
tumbler of ice water, exhausting its contained air (by suction, or by 
drawing the tube through the finger), a siphonic current is established 
through the coil. The discharge-pipe being placed on a lower plane than 
the water-supply, the current may be kept up until the vessel is emptied. 

The rapidity of the flow can be regulated either by raising or lowering 

*Reprinted from the New York Medical Record, January 9th, 1875. 



GONORRHCEA AND ITS SEQUELS. 465 

Firm pressure with the fingers on the urethra, just 
behind the posterior edge of the cut, and a closure of 
the meatus with the fingers of the other hand is a ready 
method of arresting a sudden gush, which may come 
on urination or in consequence of an erection. This is 
rare, however. The worst that can happen should always 
be anticipated in every case, and be thoroughly pre- 
pared for; but in the very greatest majority of cases the 
haemorrhage needs but little more than the folded 
towel, except watching for the first three or four days, not 
forgetting to keep in mind the liability to erections and 
consequent tendency to haemorrhage during sleep, and 
especially after operative interference of any sort. If 
the bleeding comes from so far back that it becomes 
difficult of control on this account, as in the vicinity 
of the bulb, it may ooze into the bladder. The pe- 
rineal crutch can be readily extemporized, and with a 
graduated compress in the perineum the crutch so 
arranged that its foot will bear against some firm point 

the end of either tube, which is the simpler plan ; but the more convenient 
one is by a tapering, double silver tube, attached to the discharge- pipe, 
a sponge being fitted to the inner tube. This sponge, when the inner 
tube is pushed down into the smaller end of the outer tube, becomes 
compressed and gradually obstructs the flow of water, until not a drop 
will exude. This contrivance may be regulated so that either a free 
stream can pass, or that the single drops shall follow each other, more or 
less rapidly, with the regularity and precision of a timepiece. 

By means of this arrangement, I have been able to apply cold to the 
penis or scrotum continuously and conveniently both to the patient and 
to myself. The coils of tubing are retained in position by a band of cot- 
ton or linen cloth. A ready method of constructing this apparatus is by 
placing a strip of thin cloth, six inches in length and two in breadth, 
lengthwise, upon a large speculum or a four or six ounce vial. The tub- 
ing, taken at the middle of a piece six or seven yards long, is wound 
around the vial, and, after the requisite number of turns are made, the 
projecting ends of the cloth are doubled over and stiched to the under 
layer between the turns of tubing, If, after completion, the turns are 
found too small, they may be readily enlarged by drawing the tubing 
through the cloth to any desired extent. 

I have found this simple contrivance of essential service in the acute 
form of gonorrhoea, reducing inflammatory action promptly, and thus 
giving relief to painful micturition and erections. 

It has proved of great value in keeping down inflammation and in pre- 
venting erections after the operation of circumcision. I habitually use it 
for the same purpose in operations for stricture, and with results more 
prompt and satisfactory than those hitherto attained by any medication 
or application with which I am familiar. 



466 GONORRHOEA AND ITS SEQUELS. 

at the foot of the bed, and the opposite end press against 
the compress. This has the advantage of elastic band- 
ages sometimes used as being easily arranged and con- 
trolled by the patient allowing the weight of his body 
to bear upon the crutch, when necessary to arrest the 
bleeding, and easing up on it when it has ceased. This 
may be readily made by cutting a broom-handle of the 
proper length, and tacking across one end a small bit of 
wood slightly concave to fit the perineum. If neces- 
sary, the bladder may be emptied of clots by means of 
an ordinary pint syringe and a large flexible catheter. 
This process may be facilitated by mixing a drachm of 
pepsin with two or three ounces of water, and injecting 
this into the bladder. The solution of the clots are in 
this way speedily effected, and the bladder may then 
be easily emptied. On account of the liability to free 
and possibly dangerous haemorrhage after division of 



G.TiEMamatco 



Fig. 11. Perineal Crutch. 

stricture in the deep urethra, and the difficulty of con- 
trolling it, I do not advocate division of strictures with 
the dilating urethrotome beyond the bulbo-membranous 
junction. Strictures beyond this point, which are not 
readily dilatable to full size of urethra by means of steel 
sounds, are best and most safely divided by external pe- 
rineal urethrotomy. 

Reference to statements previously given, show that 
strictures beyond this point are rare, most of the alleged 
strictures in the deep urethra being spasmodic in charac- 
ter. After-treatment of cases where dilating urethrotomy 
has been performed consists simply in ordinary means 
of reducing irritation by rendering the urine bland, and 
the introduction of a full-sized sound on the second day 
after operation, simply beyond the site of former stric- 
ture, and on no account passing it into the bladder. 
This to be continued every second day, until healing 
has taken place. This usually requires from 10 to 12 



GONORRHOEA AND ITS SEQUELS. 467 

days. If all goes on favorably the patient may usually 
visit the surgeon at his office after the fourth or fifth 
day, especially where the incisions have not been ex- 
tensive. In the introduction of sounds, or in fact of any 
urethral instruments, no force should be used. Simply 
let the instrument, well oiled, follow down the canal 
almost if not quite by its own weight ; gently turning it 
this way and that, as a fold of mucous membrane arrests 
its progress. 

Strictures of small calibre, or those too small to permit 
the passage of the urethra-metre (18 to 20 millimetres 
circ), may be gradually brought up to this size by grad- 
ual dilatation, introducing soft or gum-elastic bougies 
of increasing sizes once in three or four days. If the 
stricture is very dense and irritable, and urethral chills 
or other troubles are caused by attempted dilatation, 
a division of the stricture tissue with the urethrotome of 
M. Maisonneuve may be advantageously used to pre- 
pare the way for the dilating urethrotome. It is a good 
plan, where the irritability of the deep urethra is not 
great, to draw off the urine for the first two or three 
days after operation. The occurrence of urethral fever 
is thus often prevented, when it might otherwise occur. 

Urethral fever is not by any means common after an 
operation by dilating urethrotomy in the anterior ure- 
thra, but seems to occur more frequently when the pa- 
tient urinates over the cut surface soon after operation. 

In persons of highly nervous temperament the pre- 
disposition to urethral fever is the rule, and any slight 
mechanical interference may give rise to it. Malarious 
antecedents increase in a marked degree the probability 
of its occurrence. The presence, likewise, of any dis- 
ease, acute or chronic, of the deep urethra, prostate 
gland, bladder or kidneys, is a very great and unmis- 
takable predisposing cause. I, therefore, hold that the 
previous recognition of any of these conditions is of the 
highest importance in the treatment of urethral stric- 
ture by any method, and, further that, in cases of long- 
standing urethral trouble, and in all elderly persons, the 
passage of any instrument through the urethra into the 
bladder should never be attempted without a preliminary ex- 



468 GONORRHOEA AND ITS SEQUELS. 

animation of the patient 's urine to determine the state of 
the bladder and kidneys. 

The predisposition to urethral fever in persons as 
above described, suggests that all possible precaution- 
ary methods should be used to prevent this accident 
whenever, as is sometimes the case, surgical interfer- 
ence becomes imperative. To this end rest in the re- 
cumbent position for a day or two is of value. Hot sitz 
baths, temp, no, for 3 or 4 minutes morning and night. 
Muriated tincture of iron and tonic doses of quinine in 
persons of debilitated habit. Immediately previous to 
the proposed operative procedure I am in the habit of 
administering 5 to 10 grains of quinine (preferably 
10) in pill or capsule, or instead of this, a suppository 
composed of ten grains of the bisulphate of quinine and 
a quarter of a grain of the acetate of morphine. It is 
not from the fact that urethral fever in such cases is 
more likely to occur, and with possibly greater sever- 
ity, than in healthy persons, that this predisposition is 
important, but because when it does occur, the danger 
of the reflex irritation extending to the ureters and kid- 
neys, and inducing a suppression of urine, is greatly 
increased, and that suppression so induced is frequently 
and rapidly fatal. 

In cases of rise of temperature, after operation with 
or without distinct rigors, I am in the habit of adminis- 
tering 5 grains of quinine every 6 hours, and a drop of 
aconite every half hour or hour, until the fever subsides, 
which is usually within 24 hours. Slight swelling of the 
penis, due to a localized inflammation of the spongy ure- 
thra at the point of incision, occasionally occurs. I have 
seen three cases of this sort out of over 1000 operations. 
This subsided in these cases within a few days without 
other treatment than weak carbolic injections, 5 grains to 
an ounce and the use of the cold-water coil. Dr. Bevan 
of Baltimore, in his report of 200 cases operated on, com- 
prising 446 strictures, reports the occurrence of 4 peri- 
urethral abscesses. I have never met with such an 
accident. Acute urethritis sometimes results from the 
previous existence of an irritating purulent discharge. 



GONORRHOEA AND ITS SEQUELS. 469 

Such an accident contra-indicates the use of sounds, 
until they may be introduced without especial pain. 

Inflammation following the operation sometimes gives 
rise to chordee, and may continue, leaving a curvature 
persisting for several weeks or months after the wound 
of operation has healed. I have, however, never seen a 
case where the plastic exudation causing it was not final- 
ly absorbed. Two cases have come to my knowledge, 
where the frequent passage of sounds (daily) was kept 
up, notwithstanding an acute inflammation was present, 
and where curvation resulted which gave great annoy- 
ance for over a year. One where the introduction of 
sounds was daily practised for six weeks, with so great 




Fig. 12. Author's Dilating Urethrotome for Diagonal Division. 

pain that ether was required to effect it, and yet this 
case finally recovered. In the other, operated on a 
little over a year ago, aggravated in the ,same way, the 
curvature still persists. Such rare cases, evidently due 
to gross error in after-treatment, cannot legitimately 
count against the operation, when well and judiciously 
performed. Several cases of persistent curvation of 
the penis resulting solely from gonorrhceal inflamma- 
tion and consequent stricture have come under my no- 
tice, and which have been reduced by the operation of 
dilating urethrotomy by cross section of the constrict- 
ing band with an instrument especially devised for this 
purpose dividing the stricture diagonally. 



470 GONORRHOEA AND ITS SEQUELAE. 



LESSON LVI. 

SPASMODIC STRICTURE, OR URETHRISMUS. 

Spasmodic urethral stricture — Chronic spasmodic stricture, or ureth- 
rismus — Clinical cases in illustration — Case I., of seventeen years' du- 
ration — Complicated with incontinence of urine, etc. — Cured by divis- 
ion of a contracted meatus urinarius combined with over-distension 
of the membranous urethra — Case II. — Case treated for close or- 
ganic stricture by eminent surgeons — Subsequently proved to be spas- 
modic and cured by division of anterior strictures of large calibre — 
Case III. — Treated for close, deep organic stricture for three years — 
Completely relieved by division on anterior stricture of large calibre — 
Case IV. — Treated for impassable deep stricture for years — Repeated 
aspirations of the bladder for prolonged retention of urine — Promptly 
and permanently relieved by division of anterior strictures of large 
calibre. 

The occurrence of obstruction to the passage of in- 
struments through the deep urethra is frequent, and 
yet it has been shown that organic stricture beyond 
the bulbous urethra is exceedingly rare. In the very 
largest proportion of cases this obstruction is due to 
the spasm of the muscular or membranous urethra, 
caused by the irritation consequent upon stricture in 
the anterior portion of the canal. The following cases 
will show how readily the error of mistaking spasmodic 
stricture for organic stricture may be made : 

Case I. — A gentleman, set 39, holding an important 
government position, came under my observation in 
October, 1875, with the following history : Acute ure- 
thritis, from contagion, at the age of fifteen, (1857,) se- 
vere, and followed by a gleet, which lasted, under a 
varied treatment, for three years. In 1856, another 
acute attack, following a suspicious contact, lasting 
several months. No subsequent exposure. In 1858 
took a long, hard, horseback ride, with a young lady, 
during which had urgent desire to urinate, but was 
obliged to postpone for several hours. When opportu- 
nity occurred, could not ; retention complete ; was fin- 



GONORRHOEA AND ITS SEQUELS. 47 1 

ally relieved by the introduction of a catheter. Since 
that time has always had more or less trouble in urina- 
tion ; frequent attacks of retention after vinous excess, 
or fatigue, one lasting for thirty hours. In 1862 came 
under the care of a distinguished surgeon who, after 
examination, attributed the trouble to a close, organic, 
stricture in the membranous urethra. Internal urethro- 
tomy was performed. After recovering from this opera- 
tion, the patient, as directed, passed a catheter himself, 
at stated intervals, often leaving it in from one to two 
hours. After a few months, neglecting the use of the 
catheter, he had another attack of retention. Another 
surgeon was called in, who attempted divulsion. The 
instrument " got jammed," (as the patient expressed it,) 
and, in withdrawal, several shreds of mucous membrane 
were found attached to it. Much and prolonged suffer- 
ing resulted. His general health became impaired, suf- 
fering also from occasional retention up to 1867, when, 
without special treatment, he began to improve, and 
went on active duty. He was, however, at this time, 
much annoyed by habitual incontinence of urine. In 
1 87 1 went under the care of the late Dr. Armsby, of 
Albany. Then followed two months of treatment ; 
patient confined to bed. During this time systematic 
and prolonged but fruitless efforts were made to enter 
the bladder. The operation of external perineal ureth- 
rotomy, without a guide, was then proposed as the last 
resource. This was declined. Some improvement in 
the incontinence taking place during the following few 
months, patient went on special duty. From 1872 to the 
present time, has had much incontinence, and occasional 
attacks of retention which were caused either by excite- 
ment, cold or wet feet, or any interference with the 
general health. Relief had been attempted by various 
surgeons, resulting in much haemorrhage in several in- 
stances, but in no instance was the surgeon successful in 
entering the bladder. Relief always came spontaneously 
during sleep. After rising from stool, a certain amount 
of urine habitually escaped. This seemed to the patient 
to " collect in the urethra just in front of the anus." 
Can now control the urine during the day ; voiding it 



472 GONORRHOEA AND ITS SEQUELS. 

at will, but in short, irregular jets, or in drops — never 
having the feeling of completely emptying the bladder. 
During sleep the urine dribbles off, completely emptying 
the bladder. Retention occurring during the day is 
often relieved by letting warm water run on the wrists. 
Urine can never be passed, even in drops, in the pres- 
ence of any one. 

Present Condition. — Great nervous debility ; easily ex- 
cited ; very irritable ; tremulous, starting on slight 
occasions ; appetite variable — generally poor ; weight 
114 lbs. Urine examined, and found to be normal. 
The patient refused to submit even to the most super- 
ficial physical examination, except under the influence 
of an anaesthetic, and this he desired to postpone for a 
couple of weeks. He was directed to take quinine and 
iron, and to rest in a recumbent position for three days 
previous to the proposed examination. 

At if P.M., October 29th, the patient was brought un- 
der the influence of the nitrous oxide gas, and then of 
ether, (through the apparatus of Mr. Clover, of Lon- 
don,) by my associate, Dr. L. Bolton Bangs. An ex- 
amination was then made, resulting as follows : Genital 
apparatus well formed, circumference of penis, 3 J inches, 
meatus 24 f. urethra 31 f. to 2f inches, at which point it 
was contracted to 26 f. Three distinct bands in the 
succeeding inch, urethra then enlarging to 32 f., was 
clear for this size bulb, to the bulbo-membraneous junc- 
tion. Here, however, an obstruction was met, which 
resisted the passage of gradually decreasing sizes, of 
both solid and flexible instruments, down to the finest 
filiform bougie. I then divided the contracted meatus 
to 31 f., and with the dilating urethrotome raised the 
same point, incised the contractions from 2\ to 3i inches. 
Then began a patient and systematic endeavor to pass 
the deeper obstruction. This lasted a little more than 
one hour, (during which time, the anaesthetic was re- 
peatedly carried to stertor,) when, finally, a fine English 
filiform guide-bougie was insinuated, closely hugged, 
through the obstruction and well into the bladder. Af- 
ter remaining for a minute or two, it was found to be free, 
and easily movable ; suddenly, it was again closely held. 



GONORRHOEA AND ITS SEQUELS. 473 

This occurred, first in my own hands, and subsequently 
in those of my associate, Dr. Bangs. From the outset, I 
had strongly suspected the obstruction to be, in a great 
measure, spasmodic. The first occurrence of trouble 
after the long, hard ride, and a prolonged voluntary re- 
tention of urine ; the subsequent failure to get substan- 
tial relief by the deep urethrotomy ; the frequent sub- 
sequent retentions and incontinence, and failures of 
skilled surgeons to enter the bladder with even the 
smallest instruments ; more than all, the spontaneous 
and thorough emptying of the bladder during sleep, and 
finally, the obstruction playing "fast and loose," with 
the small bougie I had succeeded in passing. 

All these considerations combined to give me an as- 
surance, almost positive, of spasmodic stricture, de- 
pendent upon an anterior urethral irritation ; but I had 
already removed the anterior obstructions, and yet the 
passage of large instruments was resisted. I fully be- 
lieve that, with patient effort, the spasm of the compress- 
ores would give way ; but the patient had been under 
aether for more than an hour, and I could not consent 
to forego the advantages already gained, on an uncer- 
tainty. I therefore screwed on the staff of the urethro- 
tome of Maisonneuve, and attempted its entrance. After 
passing it down three or four inches the guide was ar- 
rested : gently pressing it for a few minutes, without 
the assurance of free progress, I withdrew it and found 
that the filiform guide was doubled back upon the staff. I 
then unscrewed the guide and attempted the passage of 
the plain staff. This, after gentle, persistent pressure, 
some five minutes or more, guided by a finger in the 
rectum, resulted in its passage through, and well into 
the bladder. The blade of the instrument, (cutting up 
to twenty-two, was then passed down, meeting with 
scarcely any resistance in the membranous urethra. On its 
withdrawal a 31 f. solid steel sound was passed and 
without force into the bladder. 

I was then fully confirmed in my original impression 
that the deep obstruction was mainly if not entirely 
spasmodic. The blade of Maisonneuve which had 
been passed could only cut up to 22 i . and yet it had been 



474 GONORRHOEA AND ITS SEQUELS. 

easily followed by a solid-steel sound number 31. The 
bare fact, however, that cutting had been done, more or 
less, would warrant the inference that the obstruction 
was organic and had been removed by the 22 blade of 
M. Maisonneuve. It was a matter of great regret that a 
more prolonged trial with a large sound had not been 
made before resorting to the knife, but this was una- 
vailing, and the question of the true nature of the ob- 
struction was necessarily left in doubt. The operation 
was completed at 3 p.m. of the 29th of October, having 
occupied one and a half hours. A suppository of quin. 
sulph. gr. x and morph. sulph. \ was administered and 
the cold-water coil applied. 

8 p.m. — Patient suffers from neuralgic flashes in both 
hips, quite severe ; has frequently suffered in the same 
way during attacks of retention. At 10 P.M., he passed 
water in full stream, but with considerable pain. Four 
hours after, (30th, 2 a.m.,) had a sharp chill, lasting an 
hour; followed by fever and sweating. Suppository 
quinine 10 gr., and morphia J, repeated. At 10 A.M. 
again passed water in full quantity, with much less 
pain. At 12 o'clock, (two hours after urination,) had 
another chill, but much less severe than the first. Men- 
tal depression very great. Some sciatic pain. 

October 31^, M. — Has had no more chills, passed water 
in good stream ; no more neuralgia. Pulse and tem- 
perature normal. No more incontinence during the 
day, much less at night. Still much demoralized, but 
hopeful. 

November 1st — Still improving. Nitrous oxide gas 
administered by Dr. Bangs, and 31 steel sound intro- 
duced. No resistance to the passage of the instrument ; 
bleeding slight. Four hours after the introduction of 
the sound, he had another chill, followed by a tempera- 
ture of 103 . Quinine and morphia administered as be- 
fore, and stimulating liniment applied along the spine. 
Another chill six hours later, one hour subsequent to 
urination. After this, patient improved rapidly. Free 
from pain. No incontinence day or night. Quinine 5 
gr. three times a day. No other treatment up to No- 
vember 4th. On this date the gas was again adminis- 






GONORRHOEA AND ITS SEQUELAE. 475 

tered, (without which the patient would not submit to 
the least interference,) and 31 solid sound again intro- 
duced. Chill followed four hours after, temperature ris- 
ing again to 103 Fahr. Nothing noteworthy subsequent 
to this until the 6th, when under gas, the sound was 
again passed. No recurrence of urethral fever. Sound 
passed again on the 8th. Went out walking on the 9th. 
From this the improvement was steady and rapid up to 
date, November 13th. No further introduction of in- 
strument. Urine is now held, with ease, for six hours, 
and passed in large stream, promptly and without dis- 
comfort. General bodily and mental health greatly im- 
proved. Goes into the country to-day for a few weeks. 

November 26th. — The patient again presents, saying 
that, after leaving New York on the 13th of November, 
he had continued to improve for a week or more, neither 
troubled with incontinence nor pain ; nor any marked 
difficulty in emptying the bladder. At the end of that 
period, however, he began to notice less control over 
his urine at night, and the stream diminished in size 
within twenty-four hours, so that he was in as bad a 
condition, apparently, as ever. He stated, however, 
that he had no pain, and could empty the bladder at 
will, though only by drops, or fine, short jets. The re- 
turn of trouble was attributed by the patient to exposure 
in a cold out-side water-closet, repeatedly, during a long 
and severe storm ; confinement to house, and want of 
his accustomed exercise. He is much, discouraged on 
account of the return of his incontinence at night, and 
his frequent necessity to urinate during the day, but 
suffers no pain. 

The sudden return of incontinence and difficult urina- 
tion, pointed very squarely to a spasmodic cause, rather 
than to recontraction of stricture. The patient was at 
once put under suppositories of extract hyoscyamus gr. 
4, and extract belladonna gr. |, every six hours, with 
quinine and iron internally. During the next three 
days, the condition of the patient was not materially 
altered, although the constitutional effect of the sup- 
positories had been had. 

On the 29th of November, an examination under 



476 GONORRHOEA AND ITS SEQUELS. 

the nitrous oxide gas, showed a re-contraction of the 
urethral orifice to 24 f. This was now freely divided to 
33, and 32 solid steel sound passed without difficulty to 
the bulbo-membranous junction, where it was abruptly 
resisted. Decreasing sizes were then tried, but without 
avail, until a filiform No. 1 was used. This passed into 
the bladder, but was quicklv grasped in the membran- 
ous urethra, as on the occasion of the first operation. 
The spasmodic element was now so pronounced at this 
point, that it was thought wise to defer any further in- 
terference until the full effect of the division of the re- 
contracted meatus should be ascertained. 

November 30th. — Urination easy in a full, round stream* 
This improvement, with complete relief from inconti- 
nence, continued until December 2nd, when the tissues 
at the meatus became inflamed, and the urinary troubles 
returned, dribbling as bad as ever: urination frequent ; 
lotio plumb, et. opii applied. 

December 3d. — Inflammatory condition better, and pa- 
tient passes quite a fair stream. Only 30 bulb can be 
introduced through the meatus. 

At 12J p.m. of this date, patient was again brought un- 
der the influence of the nitrous oxide gas and ether, and 
the meatus incised, so that 34 f. bulb passed with ease. 

A large and very flexible bougie (11 f. at the point 
and 30 from three inches,) slipped over a small sound to 
give it resisting power, was then passed down to the 
bulbo-membranous junction. Here it was steadily held 
in line with the sub-pubic curve, for five minutes, no 
yielding, although the patient was well under the influ- 
ence of ether. I then withdrew it, and passed down a 
32 blunt-pointed solid steel sound and held it gently, 
and steadily pressed against the resisting muscular 
spasmodic contraction, for nearly ten minutes. The 
ether was then carried to profound anaesthesia, when 
suddenly the sound slipped into the bladder. I then 

* At 6.30 p.m. of the 29th, patient writes a note, saying : " Dear 
sir : I have just passed an unbroken, fair-sized, and nearly round stream, 
with no dripping, until it was nearly all out, and no pain. When I say 
fair-sized, I mean compared with anything except my few days of first 
great relief. Yours truly, ." 



GONORRHOEA AND ITS SEQUELAE. 477 

took No. 34 f., and passed it, closely hugged, but with- 
out undue force, up to the handle, and thus well into 
the bladder. My object was, mainly, to over-distend 
the muscular urethra, as in the operation for vaginismus, 
to which the condition of the membraneous urethra and 
its surroundings seem to me to be analagous. Bleed- 
ing very slight, and apparently from the incised meatus ; 
administered suppository, 10 grs. quinine, and J gr. mor- 
phine. At 5 P.M., patient had a sharp chill, with severe 
sciatic pains, and followed by fever and sweating. At 
8 P.M. six drops of Magendie were administered by hy- 
podermic injection ; asleep in two minutes. Patient had 
a fair night, free from pain. Urine passed into urinal 
during sleep. 

December \th. — At 9^, temperature 98 J°, pulse 100, 
feels well ; no further interference, except to continue 
quinine, 5 gr. every eight hours. 

December $t/i. — Passed a good night ; some sciatic 
pains, no fever ; passes a full large stream, emptying the 
bladder with a single effort. 

December %th. — Still doing well ; no incontinence, 
passes his urine at will, in full stream ; is much troubled 
with sciatic pains. For the last three days No. 32, solid 
sound, has been passed daily through, and somewhat be- 
yond, the meatus, but always with the effect of bring- 
ing on or increasing the sciatic pains. There is now 
slight purulent urethral discharge. To stop all instru- 
mentation. General health has not improved, appetite 
poor, and digestion difficult. Is taking quinine, Hors- 
ford's acid phosphates before, and pepsin after meals ; 
to go out for a ride. 

December i^tk. — Sciatic pains have been relieved by 
the galvanic continued current ; digestion improved. 
Urination free and painless ; no incontinence. Goes 
home to-day with directions to continue the acid and 
quinine, to take exercise in the open air, but to cease all 
interference with genito-urinary apparatus, except by 
use of a mild injection for the slight urethral discharge 
which has remained since the last operation. 

A few days later I received a letter, dated December 
16th, from which the following is an extract : " The 



478 GONORRHOEA AND ITS SEQUELS. 

journey (two hundred miles,) had no ill effect on me, 
further than to make me stiff and tired, my sciatic leg 
holding itself upon the verge of mutiny ; so I laid quiet 
and petted it. The next day I got up and down two 
pair of stairs, forty-six steps, twice ; taking a three block 
walk, and two quite heavy meals. Leg still stiff and 
sore. That brings me up to to-day, which records 
" better." My stream of water retains its large size, and 
gives me a good deal of satisfaction and no discomfort. 
The discharge and irritation are improved, but the for- 
mer is not quite over. My appetite is good, and I think 
I shall gain quite rapidly now that I have begun to 
walk and eat." 

January 29th. — A little more than seven weeks from 
last operation, patient called and reports : From date of 
last minutes, a gradual improvement for three weeks ; 
then improved rapidly, as only then did the sciatica 
quite leave him. The sciatic trouble was not in shoot- 
ing pains as before, but in sore spots from the middle 
of the gluteal region, passing down the thigh of the 
same side. No sense of soreness, on pressure, at any 
point. Appetite good ; has increased in weight from 
114 lbs. to 122 lbs. Makes a full stream, which he can 
project to the distance of three feet, but thinks, after long 
fatigue, his stream is not so strong. His spirits are 
good. He has entirely recovered from his mental de- 
moralization ; works perfectly well on close mathemati- 
cal problems for six hours on a stretch. For two years 
before the operation no semen passed, although he had 
all the sensations. Since then it passes perfectly at 
every orgasm. This trouble he states was the cause of 
his depression of spirits ; feeling, as he expressed it, 
" like a eunuch." 

March gth. — Called ; this morning, in good condition. 
Has gained seventeen pounds since the operation, and 
is quite well of his urinary trouble. When he is much 
fatigued, mentally, thinks the water comes too slowly ; 
when he is rested, it is all right, is in fine spirits. Has 
been overworked, and is off for a week in the Adiron- 
dacks. 

May 20th. — Called ; has gained in flesh, and is in per- 



GONORRHCEA AND ITS SEQUELS. 479 

feet health, with not a sign of his former genito-urinary 
trouble. 

November 12th, 1876. — A grateful letter received, in 
which he, my patient, says : "I write to tell you that / 
am in the very best of health. My old enemy, conqured 
at almost the moment of victory, has taken his place 
where memory alone can reach him. Literally, I weigh 
142 lbs., and am well" The last report from this pa- 
tient was in 1881 at which time there had been no re- 
currence of his urinary trouble and he was in good 
general health. 

In concluding the report of this remarkable case, I 
will only say, that it is in the line of my experience and 
observation, to find strictures at the meatus, and ante- 
rior portion of the urethra, associated with all the symp- 
toms of deep organic stricture. In my article on Spas- 
modic Strictures, published in the Archives of Dermatol- 
ogy, Vol. 1, No. 3, (1875,) several such instances will be 
found. The foregoing case exemplifies, in a striking 
manner, the influence of anterior contractions in pro- 
ducing and perpetuating spasmodic stricture, of a char- 
acter ide?2tical in every respect with true organic con- 
traction of the deep urethra, and which, as shown in the 
above case, resists every form of treatment, which does 
not include complete restoration of the anterior portion 
of the canal, to its normal dimensions. 

Case II. — "Bernard O. C* ast. thirty -five ; was ad- 
mitted July 31,1 878. Patient had gonorrhoea nine years 
ago, the discharge becoming gleety and lasting for six 
years. In the fifth year of the disease he had a perineal 
abscess, which healed after remaining open for ten weeks, 
other formed at the same site about four weeks before 
admission, having a fistula which had not yet closed. 
When admitted he passed stream of urine about size 
of knitting-needle. Examination of urethra detected 
obstruction about five inches behind meatus, admitting 
only filiform bougie. At the same point, steel sound 

* This case was reported by the late Dr. C. M. Allin to the Medical 
and Surgical Society of New York in 1878, and published in the Hospital 
Gazette of June 28, 1879, in the author's controversy with Prof. H. B. 
Sands on spasmodic stricture. Cases III. and IV. are also from the same. 



480 GONORRHOEA AND ITS SEQUELS. 

No. 25 f. entered what appeared to be a false passage. 
High fever, with thrombosis of left femoral vein fol- 
lowed this examination, and no further mechanical 
treatment was undertaken until Sept. 26, when the 
deep stricture was found impassable to filiform bougies. 
The perineal fistula admitted a probe, which passed 
about an inch upward and backward toward the blad- 
der. Sept. 28 : Operation. Patient astherized. Flexi- 
ble bougie No. 5 f., entered the bladder with difficulty, 
encountering resistance in the perineum ; meatus which 
admitted No. 25 f., incised, and with No. 22 f. strictures 
diagnosticated at 2-§- and 4-I inches from meatus. These 
were cut with the dilating urethrotome to No. 37, 
after which sound No. 35 passed without difficulty into the 
bladder" 

Another case, occurring in the service of Dr. Geo. 
A. Peters, and extracted from the records of the New 
York Hospital : 

Case III.— F. Whitehead, 33, April 20, 1878. Twelve 
years ago had gonorrhoea, followed by stricture. Re- 
lieved by bougies. No trouble until three years ago. 
Then gradual decrease in size and force of stream — 
spiral. Past year urinated only drop by drop. Before 
operation meatus admitted 18 f. to 3 J inches 5.14 f. 
passed through this to 4J inches. Beyond that only fili- 
form passed, with difficulty. Internal urethrotomy by 
Dr. Peters, April 26, 1878. Etherized. Meatus slit with 
bistoury. Urethra injected with olive oil and meas- 
ured. Filiform passed into bladder, followed by Mai- 
sonneuve's director. Urethrotome (blade) with cutting 
capacity of 12 mm. passed, dividing only arterior stric- 
ture. As No. 25 f. would not pass the 4% stricture, 
Maisonneuve again introduced. After which No. 25 
F. passed down to 6 inches and stopped. Beyond this 
only No. 15 f. flexible passed. 

Otis's urethrotome introduced, dilated to 40 mm., and 
anterior strictures divided, when No. 36 f. passed, 
without any difficulty into bladder, showing that obstruc- 
tion at 6 inches was only spasmodic and depended on stric- 
tures of large calibre, and anteriorly" 

Another case, this in my own practice : 



GONORRHOEA AND ITS SEQUELS. 48 1 

Case IV. — Mr. D. J., planter, aged 35, was referred to 
me June 19, 1877, by Drs. A. Y. P. Garnet and N. S. Lin- 
coln, of Washington, with the following history. First 
and only specific urethritis in 1865 ; severe at the outset, 
but soon painless, and from that time has never been quite 
free from a urethral discharge. Two years after, [1867,] 
began to appreciate a lack of force in urination with 
dribbling after the act. In 1867- 68-69 was in the rail- 
road service, which aggravated his trouble. Nothing 
serious, however, until 1871, when after an enforced 
holding of his urine for several hours, he had an attack 
of retention. This, after eight hours of suffering, was 
reduced by the introduction of a catheter. No especial 
trouble again, except frequent urination, until in 1874, 
when, after overwork and neglect he had a second 
retention 12 hours — relieved by anodynes. Another 
a week subsequent, his physicians attemoted to pass 
catheter, but failed ; bled him from the arm ad deli- 
quium, when he urinated. After this retentions were 
frequent, accompanied by severe vesical tenesmus, 
which finally produced prolapsus of rectum, great pain 
in region of bladder and kidneys during attacks of 
retention, also severe pain in the eyes, from straining. 
Repeated and prolonged efforts, by various medical 
men to introduce a catheter, failed in every instance. 
Urination now every half hour and small in quantity, 
and inability to completely empty the bladder. This 
last became much distended, a?id remained so, notwith- 
standing frequent urination in small quantity. Suffered 
much from straining, in attempts to urinate, during 
subsequeni time, up to Feb., 1877, Although repeated 
trials had been made by various surgeons, no instru- 
ment had been passed into the bladder since 1871, and, 
for previous three years, bladder habitually distended ; 
protuberant. 

At this time, a surgeon proposed to dilate his stric- 
ture, which was supposed to be in the deep urethra. 
No. 14, steel sound, after gentle and prolonged efforts, 
every morning for three weeks, preceded by a hot hip 
bath, was finally passed into the bladder. About a pint 
of urine followed the withdrawal of the sound. To this 



482 GONORRHOEA AND ITS SEQUELS. 

succeeded strong and painful twitchings of his limbs 
and severe pain in hips and over kidneys, also buttocks 
and thighs. This was followed, very soon, by a severe 
chill and fever and sweating. A similar attack of fever 
came on for four days succeeding, and he did not recover 
his usual health for five or six weeks. After this, any un- 
usual fatigue brought on chills. May 19, 1877, he went to 
Washington, and came under the charge of Dr. Garnet. 
A careful attempt to introduce a small catheter failed. 
On the 22d, four days after, Dr. G. associated Dr. Lin- 
coln with him, and the patient was put under the influ- 
ence of chloroform and ether and careful, persistent, 
trials were made with a variety of instruments to enter 
the bladder, all of which were resisted. The bladder 
was then aspirated and over a quart of urine drawn off. 

On the 31st, efforts under anaesthesia were again 
made, for three-quarters of an hour, with result as be- 
fore. Bladder again aspirated, and about the same 
amount of urine drawn as before. 

On the 5th of June another attempt under same con- 
ditions. Same result. On the 10th, again ; three pints 
drawn off. On the 17th, same. 

Thus all efforts which appeared judicious were made 
to enter the bladder, and the bladder was aspirated five 
times during the month. In the intervals the patient 
was out and able to take a little exercise, urinating 
every hour about a teaspoonful, sometimes with ease, 
at others with straining. Since August, 1876, has not 
been able to retain his urine when standing, and has 
worn a urinal habitually. Occasionally complete re- 
tention would occur, when, after application of hot 
cloths for a few hours, relief in the usual small degree 
would come. He left Washington for New York on 
the 20th of June, 1877, having been last aspirated on the 
17th. During his railway journey he urinated with 
unusual ease and freedom, but had an attack of reten- 
tion on his arrival in New York, which was as usual 
relieved by hot cloths. This was the history given to 
me by the patient. He was tall, spare, with an expres- 
sion of habitual suffering and irritability. Examination 
showed a large penis, measuring 4^ inches in circum- 



GONORRHOEA AND ITS SEQUELS. 483 

ference ; meatus small and pouting ; bladder protuber- 
ant and dull up to within an inch of the umbilicus. No 
enlargement of the prostate. 

Examination with the urethrometer. This was car- 
ried into the bulbo-membranous junction, and turned 
without discomfort up to forty. Clear to this size for 
three inches, then required to be turned down to twen- 
ty-eight. Three bands of stricture of 28 were' recog- 
nized within an inch. The urethra was then found free 
from that to within half an inch of the meatus, where it 
was twenty-five m.m. to the orifice. The history of the 
patient presented some points so similar to that of the 
case of chronic spasmodic stricture of seventeen years' 
duration (cited at page 470 et seq.), that I felt strongly 
inclined to consider the deep stricture, which was evi- 
dently in the membranous urethra, as spasmodic. I 
resolved to test this. I made no attempt to introduce 
an instrument into the bladder. Under the influence 
of the nitrous oxide gas, administerd by my associate, 
Dr. Bangs, I divided the meatus urinarius to 40 F., and 
in order to test the the influence of this procedure I did 
nothing else. 

On the following morning, the patient announced that 
he had since the operation made his water more eas- 
ily than for three years, but the amount was small, and 
the bladder was not perceptibly diminished in size. 
This result made me still more confident of the spas- 
modic nature of the deeper obstruction. On this day, 
June 23d, 3J- p.m., Mr. D. J. was placed fully under the 
influence of ether, and with the dilating urethrotome 
I divided the strictures, all of which were anterior to 
4 inches (the smallest 25 m.) up to 42 m. I then passed 
what I supposed to be a 40 solid steel sound with ease 
through the urethra and well into the bladder simply by 
its own weight. I then passed a very large gum ca- 
theter and drew off two pints of urine. Dr. Bangs 
now called my attention to the fact that the first in- 
strument passed was only 36. I then took No. 40 and 
passed it with perfect ease well into the bladder. Slight 
haemorrhage followed the operation. No chill. Atone 
o'clock A.M., Mr. J. got up and urinated in a large 



484 GONORRHCEA AND ITS SEQUELS. 

stream, with complete ease, passing a full pint of urine 
and completely emptying the bladder. 

From this time he had no further trouble, except 
the slight discomfort of urinating over the cut surface 
for a few days until it healed. At the end of a couple 
of weeks, he was to all appearances, and as he said, 
"as well as ever in his life." He remained practically 
well for nearly a year, when he returned with some dif- 
ficulty of micturition, but had had no retention or 
pain. 

Examination showed a recontraction of the meatus 
to 34, also two bands, one at 3^ and the other at 4 
inches, also 34. 

He was put under ether, and the recontractions fully 
divided. An attempt to pass a full-sized instrument 
was then made. No. 40 solid sound went easily to the 
bulbo-membranous junction, but was arrested there. 
No force was used. No. 36 was then tried in the same 
manner, gently and patiently. The same result both 
with and without a pressure in rectum. Then No. 30 
was tried in the same way, then No. 20, then 10, finally 
down to fine filiform bougies in variety. This proce- 
dure occupied nearly an hour without success, when 
it was decided to make no further effort until healing 
of the wound had taken place, and all possible irrita- 
tion from this source had ceased. 

The patient passed a good night ; no chill ; urinated 
three times with ease. The stream gradually decreased 
in force, however, for the next five days, when on Sun- 
day, April 28th, 1878, he called at my office. Urinated 
in my presence in a slow, hesitating stream, but with- 
out pain. Placing him in the recumbent position on a 
lounge, I attempted to pass a No. 5 filiform bougie. 
This, after a few minutes of gentle effort, slipped 
quickly and easily into the bladder, and then suddenly 
became tightly hugged. Recognizing this as a rare ex- 
ample of unmistakable spasmodic stricture, I at once 
gent for my distinguished surgical friend and neigh- 
bor, Dr. George A. Peters, to verify the correctness of 
my conclusions. Dr. Peters came, and appreciated the 
facts above stated, especially the distinct grasping of 



GONORRHOEA AND ITS SEQUELS. 485 

the filiform bougie by the compressor urethras muscles. 
Dr. P. withdrew the bougie with some difficulty. No 
farther procedure was instituted. On the following 
day, the patient complained of great nervous prostra- 
tion, which, as he stated, came on soon after the with- 
drawal of the filiform the day previous. This, how- 
ever, passed off during the day, and nothing worthy 
of note occurred until May 4th, when the wound of 
operation having healed, it was decided to anaesthetize 
the patient, and again attempt the passage of a sound. 
Dr. Bangs, my associate, and Drs. J. H. Swasey and 
W. T. Spencer were present. After bringing the pa- 
tient to unconsciousness, although some spasmodic 
movement of the limbs was present, I attempted to pass 
a large sound. In this I failed. Smaller and smaller 
sizes were tried, until the small filiform, patiently used, 
was resisted. I then directed the patient to be put as 
thoroughly as possible under the influence of the anaes- 
thetic. In about ten minutes, complete muscular re- 
laxation took place for the first time. I then again took 
up the solid sound, No. 38, and passed it with ease well 
into the bladder. This was readily followed by No. 
40. Urination with ease in full stream four hours after 
the passage of the instruments. Day following, urinat- 
ing well ; feeling well ; temp. 101J-. Record of May 
13th says "Mr. J. feels well — vesical catarrh (from 
which he has been suffering for several weeks) declin- 
ing. Makes his water readily in a full, strong stream 
every four or five hours." Before leaving for his home, 
Mr. J. was anxious to have another passage of the large 
instrument, and this was done without difficulty. It 
was followed by a severe urethral fever, however, 
which lasted for several days, prostrating him very 
much, but his urination was easy and natural, not oftener 
than once in five or six hours, and thoroughly empty- 
ing the bladder. He gradually improved in his general 
health, and left for Washington about the middle of 
May. About a week after, he wrote that he had had 
some return of his urinary difficulty, but was going 
South. A few months later, I received a letter from 
him commending a relative to my care. Since then, 



486 GONORRHOEA AND ITS SEQUELS. 

although I have addressed a note of inquiry to him, I 
have not yet heard in regard to his condition. 

The foregoing cases appear to me to prove, not 
only the reality of that form of chronic spasmodic 
stricture, which I have (from its analogy to vaginismus), 
venture to term " Urethrismus," but they also demon- 
strate its dependence upon anterior strictures, or even 
less prominent causes of irritation. 

They demonstrate the fallacy of the claim that spas- 
modic stricture may be readily distinguished from or- 
ganic stricture, and that the admi nistration of ether neces- 
sarily causes the complete relaxation of reflex spasm. 



GONORRHOEA AND ITS SEQUELAE. 487 



LESSON LVII. 

REFLEX IRRITATIONS THROUGHOUT THE GENITO-URI- 
XARY TRACT. 

Reflex irritations now generally accepted as a cause of varied painful af- 
fections — Confirmation of this by eminent authorities — Incontinence of 
urine caused by contracted prepuce — Clinical cases in illustration — In- 
complete erections, nocturnal emissions and various other troubles 
caused by phymosis — Dittels' case — Pitha's — Dr. Black's case of sym- 
pathetic irritation — Syncope caused by introduction of a catheter — 
Such accidents not rare — Dr. Brown-Sequard's case of supposed cerebral 
ramollissement caused by reflex irritation initiated by a contracted pre- 
puce — Dr. Sayre's cases showing the pernicious influence of contracted 
prepuce — Cases by Sir Henry Thompson showing the influence of a 
contracted urethral orifice — Civiale's views on the influence of urethral 
contraction in producing varied reflex disturbances. 

The influence of the irritation of peripheral nerves in 
producing centric disturbance in the spinal cord, which 
may thence be transmitted to distant parts of the ani- 
mal economy (first claimed by Dr. Marshall Hall more 
than twenty years ago), has found corroboration in the 
testimony of every medical scientist since his time ; and 
besides, so much clinical proof has been accumulated 
by the medical profession at large in support of this 
proposition that it is no longer a matter for discus- 
sion. Morbid reflex disturbances are now accepted as 
occupying an important place in the recital of human 
suffering. 

Varied and grave disturbances, influencing the entire 
nervous system, are often ascertained to be dependent 
upon so apparently insignificant a cause as a decayed 
tooth, an indigestion, a simple erosion upon the cervix 
uteri, ceasing at once on the cessation of the cause. 
Dr. D. Campbell Black, of Glasgow, in his very inter- 
esting and valuable work on the renal and urinary 
organs, cites cases of retention of urine from reflex irri- 
tation, the result of an operation for hcemorrhoids. 
Trousseau has recorded cases of incontinence of urine 



488 GONORRHOEA AND ITS SEQUELS. 

dependent solely upon the irritation caused by a prepu- 
tial contraction. Dr. Sigismund Waterman, of New 
York, has shown me a case of this sort, which was 
promptly relieved by division of the prepuce. I have 
seen other similar cases, and also one marked case of 
retention of urine in an infant nine months old, which, 
after lasting- four days, was completely relieved within 
one hour by slitting up the prepuce. Seminal emis- 
sions are well known to occur as a result of phimosis, 
relief occurring promptly on ablation of the prepuce. 

Dittels relates a case where a man twenty-six years of 
age had a slight phimosis, and was the subject of in- 
complete erections, nocturnal emissions, frequent desire 
to urinate, and also of many hypochondriac symptoms, 
all of which were promptly and completely cured by 
removal of the prepuce. 

A similar case is related by Pitha. Sweigger-Seidel 
cites a case where the simple introduction of a catheter 
caused complete syncope, and yet no urethral disease 
was present. I have the record of a similar case where 
complete unconsciousness instantly followed the intro- 
duction of a bulbous sound through the meatus uri- 
narius. Every .surgeon of much experience has re- 
cognized the tendency to syncope in a considerable 
proportion of nervous patients, on the first introduc- 
tion of instruments through the meatus. 

Spasm of the bladder is noted by Dr. D. C. Black as 
occurring from sympathetic irritation, and to a degree, 
resulting in the complete closure of the orifices of the 
ureters, producing retention of urine in the ureters and 
pelves of the kidneys. Such a case I believe I have 
seen, resulting in death from uraemia, and caused by the 
rude introduction of a catheter, through a narrow stric- 
ture at the posterior border of the fossa navicularis. 
Forcible and painful contraction of the bladder followed 
immediately, with complete suppression of urine. The 
patient died uraemic twenty-four hours after. The 
bladder was found empty (with the exception of a few 
drachms of grumous blood and mucous), closely con- 
tracted and free from disease. The ureters were nor- 
mal, the kidneys highly engorged with blood, but pre- 



GONORRHOEA AND ITS SEQUELS. 489 

senting no evidence of disease. The case was accepted 
as one of acute suppression of urine. The ureters are 
known to contract vigorously under the influence of 
the galvanic current. The above case,* it now seems 
to me, was one of spasm of the ureters and bladder, 
reflected from the irritation of the end of the penis. 

Dr. Brown-Sequard, in the year 1874, related to me 
the following case : 

" While in London, during the past year, a gentleman 
was brought to me who presented all the rational signs 
of advanced cerebral rcimollissement. I had looked upon 
the case as quite a hopeless one, until noticing that the 
patient frequently applied his hand, in an absent sort 
of way, to his genital apparatus. Permission being 
accorded, examination of the parts revealed an aggra- 
vated inflammatory phimosis, complicated with acute 
balanitis. On making this discovery," said Dr. Brown- 
Sequard, " I expressed to the medical gentleman ac- 
companying and in charge of the patient my belief of 
the possibility that the apparent ramollissement might 
be due to reflex irritation, caused by the evidently 
chronic and severe irritation of the glans penis. I ad- 
vised complete division or ablation of the prepuce, and 
treatment of the balanitis, as the best and only hope for 
the patient's recovery from the brain trouble from 
which he was suffering." 

The operation was performed, and the effect upon 
the mental and physical condition of the patient was 
almost immediate. " So rapid was his recovery," said 
Dr. Brown-Sequard, that within six weeks from the 
date of the operation, he presented himself at my office 
perfectly well in every respect." 

Dr. Sayre, of New York, in the Transactions of the 
American Medical Association for 1870 has reported 
several cases of partial paralysis of the lower extremi- 
ties, associated and evidently dependent upon adherent 
and contracted prepuce. One was of a boy five years 
of age, unable to walk without assistance, or to stand 
erect — his knees being flexed at an angle of forty-five 

* Reported to the New York Pathological Society, March, 1S72. 



490 G0N0RRHCEA AND ITS SEQUELS. 

degrees. The operation of circumcision was performed 
on this lad by Dr. Say re, and " from the very day of 
the operation the child began to improve," and without 
other treatment made a rapid and complete recovery. 
In a second case, a lad of fourteen years had been under 
treatment for paralysis of his legs for several months 
without marked improvement, when it was found that 
a contracted and adherent prepuce was present, causing 
great local irritation, dysuria, and painful erections. 
The preputial contraction was recognized as a possible 
important factor in causing the paralytic trouble. Cir- 
cumcision was performed, resulting in complete recov- 
ery from the paralysis in six weeks. 

Sir Henry Thompson says :* " I have given complete 
relief to distressing symptoms of very long continuance, 
the cause of which was not suspected, by dividing an ex- 
ternal meatus, which, nevertheless, admitted a No. 6 
English catheter. I have met," he further states, " with 
three marked examples of a similar kind, in which the 
very simple operation necessary was followed by com- 
plete disappearance of urinary difficulties, which had been 
long regarded as of an extremely obscure character ."f He 
cites a single case : " J. J., aged thirty-four, a gentleman 
whom I had visited at the request of his medical atten- 
dant, in the spring of 1857, had been suffering from 
painful, prolonged, and frequent micturition for five 
years previous. He was compelled to pass water from 
three to five times every night, and every two hours 
during the day ; experienced severe pains in the back 
and loins, and general ill health. Urine was purulent, 
alkaline ; results of habitual retention and partial en- 
gorgement of the bladder. He had been treated for 
renal disease without any good effect. On examination 
I found a simple narrowing of the urethral orifice, and 
marks of previous ulceration in a small cicatrix. I 
learned," says he, " that he had had chancre seven years, 
before, which involved a large portion of the meatus, 
after the healing of which his present symptoms almost 

. — i — i — - — rrr . . .,.,... — bbs f^s — isasssas ,„■■,■- — - — : 7- — 

* " Stricture of the Urethra," second edition, p. 249. 
f Op. cit., page 253. 



GONORRHOEA AND ITS SEQUELS. 491 

imperceptibly appeared. A probe only passed through 
the opening. I divided the contraction so as to make a 
free opening. A No. 10 catheter was passed easily into 
the bladder, demonstrating that there was no other 
obstruction, and twelve ounces of urine were drawn off, 
although he had passed water just before. The relief 
was almost instantaneous — in a week it was complete. 
He has had perfect immunity from his urinary com- 
plaints ever since." 

The following quotations are from M. Civiale's " Traite 
Pratique des Maladies Genito-Urinaires, 2, Paris, 1850." 

At page 45 et. seq. of this work, M. Civiale writes 
thus: "Independent of its local sensitiveness, the urethra 
possesses another kind which may be termed sympathetic. . 
. . When this sensitiveness is aggravated, it may 
awaken sympathetic response in every organ and func- 
tion of the body. ... In many cases sympathetic (reflex) 
phenomena were manifest in the lower extremities, par- 
ticularly in the soles of the feet." 

Again, at page 354 et seq. " It is not rare to observe 
that slight encroachments upon the urethral calibre 
induce marked difficulty in micturition ; those at the 
meatus having this effect not less than those located 
farther in." 

Again, at page 160: " Strictures seldom exist for a 
long time without exciting a series of disorders of the 
genito-urinary functions, and, consecutively, in remote 
parts of the body. . . . Among these, gleet, retention 
of urine, difficult micturition. . . . That which has 
struck me forcibly in dividing a meatus, only slightly 
contracted, is the sudden and complete change effected 
in the general condition of the patient. The constric- 
tion, which seemed hardly to impede the flow of urine, 
is no sooner divided than all morbid symptoms vanish : 
the uretliral walls which were rigid, hard, and inelastic, 
immediately recover their normal condition; the 
bougie, which at first passed only with difficulty and 
pain, slips into the bladder with ease, and in five or six 
days the slight incision in the meatus heals perfectly, 
and the patient finds himself in a state so satisfactory, 
that it would be incredible, but for the fact that the 



492 GONORRHOEA AND ITS SEQUELS. 

instances are again and again repeated. An effect so 
prompt through means of which the significance is 
plain, shows that the slightest obstruction in the urethra is 
able to produce the gravest symptoms local and general." 

By the cases already cited, and many others scattered 
through the periodical literature of the past few years, 
and the positive testimony of the great French surgeon, 
M. Civiale, in support of the capacity of such obstruc- 
tions to produce reflex irritations in great variety, it is 
sufficiently shown that paresis, more or less pronounced, 
may result from irritations reflected through peripheral 
nerves, without any coincident morbid change in the 
structure of the spinal cord, and that incontinence of 
urine, retention of urine, suppression of urine, involun- 
tary seminal emissions, may, in the same manner, result 
from irritation at the extremity of the glans penis. The 
case of simulated cerebral ramollissemcnt, related by Dr. 
Brown-Sequard, occurring as a direct sequence of like 
irritation, indicates the wide range of sympathetic dis- 
turbances which may be initiated by simple inflamma- 
tory action at this point. Now, aside from the fact that 
the glans penis is known to be extraordinarily rich in 
sympathetic nerve cells, that it is the recognized initial 
point from which the physiological sexual excitement 
is transmitted throughout the male genitalia, the re- 
cords of clinical experience abound with evidences of 
the capacity and proneness of this especial region to 
produce reflex disturbances, often of a grave and lasting 
character, throughout the entire nervous system. Not- 
withstanding these facts, I believe that the full signifi- 
cance of this locality as a source of reflex irritations 
along the genito-urinary tract has not yet been appre- 
ciated ; and, further, I am convinced that many hereto- 
fore obscure difficulties and diseases of the genito- 
urinary organs may be distinctly traced to the locality 
of the meatus urinarius as the source of their initiation 
and continuance. 



GONORRHOEA AND ITS SEQUELS. 493 



LESSON LVIII. 

CLINICAL CASES IN ILLUSTRATION. 

Clinical cases in the author's experience — Case I. — Irritation at neck of 
bladder cured by division of a contracted meatus — Case II. — Great 
nervous irritation cured by a similar operation — Case III. — Spasmo- 
dic stricture caused by contracted urethral orifice, cured by its divi- 
sion — Case IV. — Imperfect erections — Despondency and nervousness 
dependent upon contracted meatus — Cured by its division — Case V. — 
Intense irritation in the urethra and at the neck of the bladder promptly 
cured by division of a contracted orifice — Repeated re-contractions — 
Followed by return of trouble — Repeated operations finally resulting in 
permanent cure — Case VI. — Pain on seminal emissions — Gleety dis- 
charge — Acute cystitis— Frequent micturition cured by division of 
stricture. 

Case I. — A. Y., physician, aged twenty-eight, con- 
tracted first gonorrhoea November 20, 1873. Severe — 
lasted four weeks ; treatment by alkalies, internally ; 
continued application of cold, and mild injections. Was 
then under my care. I noticed, on examination, that his 
penis was large and the meatus small, and called 
patient's attention to this fact when he first presented 
for advice, and assured him if he did not have a fair 
recovery, it would be necessary to enlarge the meatus. 

January 19. Patient presents, with gleety discharge 
without known cause, great irritation at the neck of the 
bladder, and frequent desire to urinate ; is certain that 
his former disease was imperfectly cured, and that it 
has come forward from the deep urethra to which it 
had extended in his original clap. I reminded him of 
his contracted meatus ; he is certain he needs deep in- 
jections, but submits to operation for enlargement of 
meatus. Cut it to 30 f.,* after which 30. f bulb passes 

* Wherever in the course of this work the letter f. occurs, following 
a number it indicates millimetres circumference on French metric 
scale. 



494 GONORRHOEA AND ITS SEQUELS. 

throughout the canal with ease : to keep the incision 
open until healing is complete. 

January 24. Patient reports immediate cessation of 
irritation in the perineal portion of the urethra on 
division of the contraction. The discharge ceased 
within forty-eight hours, and he has had no trouble 
since. 

Case II. — September 10, 1872, Mr. W., a Swede silk- 
weaver, was brought to me by his medical attendant, 
complaining of pain and general discomfort about the 
perineum, and especially of a nervous uneasiness in that 
region and in the glans penis, which prevented him 
from pursuing his avocation ; he could not sit still. 
Had had a gonorrhoea several years previous. Had 
been treated for stricture by dilatation for several 
months, but without relief. Examination showed a 
narrow meatus, No. 20 f. Stricture at two and a half 
inches, defined by 18 f. A free division of the meatus 
was made with Civiale's bistourie cach^ and of the stric- 
ture with the dilating urethrotome ; 27 f. passed readily 
through : to be kept open by daily introduction of 
sound until healed. 

September 20. Patient reports entire cessation of 
the irritation and nervous feeling immediately follow- 
ing the operation, but this returned yesterday. Ex- 
amination shows recontraction of the meatus to 20. 
Cut again freely. 

November 16. Patient again called, with the state- 
ment that he had been able to work until the day 
previous, when the irritation again returned, and he 
desired to be cut again. Examination showed a recon- 
traction at the meatus to 24. Cut again, and introduced 
30 f., which passed easily through the site of stricture at 
two and a half inches, and down to the bulbo-membran- 
ous junction. This patient called two months after 
(January 20), and had had no return of his trouble — no 
recontraction of meatus. 

Case III. — Mr. W., aged twenty -seven, had gonorrhaea 
in 1870, lasting one month, when a fresh exposure re- 
sulted in another attack, which lasted, under a sharp 
fire of injections, for six months longer. Since that 



GONORRHOEA AND ITS SEQUELS. 495 

time, has always had a return of the discharge after 
connection. Has been under treatment for stricture by 
several physicians, but none succeeded in entering the 
bladder. His last medical attendant, after treating him 
for a couple of months, said that he had no instruments 
small enough to pass, and advised him to put himself 
under my care. Examination (April 16) showed organ 
unusually well developed, meatus contracted to 24 f. 
and red and pouting, and bathed in a muco-purulent 
discharge. Twenty-four sound is arrested at five 
inches ; only fine filiform will pass, and that is closely 
hugged. 

April 19. Pass filiform with ease, follow w r ith No. 
10, and then, with some effort, with No. 16 f. after this 
the filiform is again closely hugged in the membranous 
portion ; divided the meatus freely, and introduced 
No. 30 steel sound, which passed literally by its own 
weight down through into the bladder, thus proving 
not only the spasmodic character of the deep obstruc- 
tion in this case, but its entire dependence upon irrita- 
tion caused by the stricture at the meatus. 

Case IV.— October 30, 1873. J. W., thirty-two, had 
gonorrhoea ten years ago, very severely, lasting, with 
pain and difficulty of micturition, fully six months. 
After being apparently well for three years, a gleety 
discharge appeared without new exposure. Mastur- 
bated daily from fourteen years of age to twenty, when 
he abandoned the habit. At twenty-six began to have 
nocturnal emissions, which, growing gradually more 
frequent since the last two years, have occurred almost 
nightly. He has had occasional sexual intercourse. 
Erections have been imperfect for last eighteen months, 
ejaculation taking place before the erection was com- 
plete. He has suffered much from despondency and 
nervousness. Has had no treatment except for general 
health, which much of the time has been indifferent. 
Examination shows genitals well developed and ap- 
parently normal, with the exception that while the cir- 
cumference of the flaccid penis is three inches, the 
meatus is contracted to 22 f. (the size of urethra in a 



496 GONORRHCEA AND ITS SEQUELS. 

penis three inches in circumference is, as a rule, fully 
30 f)* 

November 1. Divided meatus thoroughly, and 
passed 31 bulbous sound readily through contraction. 

November 11. Has had no emission since date of 
operation. 

December 1. Found himself getting so much better 
in spirits and feelings generally, that he ventured to 
marry on the 25th. Since that time he has had no 
trouble of any sort. Considers himself a well man. 

Case V. — Mr. W., aged twenty-five, came under my 
care f December 1, 1872. Contracted first gonorrhoea 
early in June, 1872. Was treated by the use of in- 
jections locally, and alkalies internally, until August 
1st, during which time he had no freedom from the 
discharge nor from acute suffering. About this time 
the vesical neck became involved, and he suffered much 
from frequent painful micturition. Came then under 
the care of a skilled endoscopist, who discovered num- 
erous spots of granulation in the course of the canal, 
extending quite into the prostatic portion, and applica- 
tions of a strong solution of nitrate of silver were 
made through the endoscope, which gave temporary 
relief; urination still painful every hour. 

By September 1st, after the use of pencils of tannin 
and glycerine, discharge decreased to a slight mucus. 
A spell of damp weather brought back the purulent 
discharge, with return of perineal pain and frequency 
of micturition. Tannin pencils again used, but after 
continuing for four weeks, and no improvement, patient 
was put to bed, and hot hip-baths every two hours, etc. 

*I have recently operated for congenital contraction of the meatus in 
a child ten years old, where the circumference was two inches. After 
the operation 22 f. was passed easily through the urethra. 

3% inches indicates urethral calibre 32 f. 

3i " " " " 34 f. 

3* " " " " 36 f- 

4 « » " " 38 f. 

4i " " " 40 f. 

\ Case V. and also Cases X. and XL were published by me in Dr. 
Brown-Sequard's "Archives of Medical Science," 1872, page 152, et seq. : 
"Cases of Stricture of the Urethra of Large Calibre, producing Reflex 
Irritations, etc." 




GONORRHOEA AND ITS SEQUELS. 497 

After five weeks of this treatment and various other r 
local and general, he came from his bed to me, Decem- 
ber 1, 1872. On examination, I found no difficulty in 
introducing- No. 20 f. bulbous sound, and discovered a 
firm cartilaginous stricture, extending from just within 
the meatus, one-half inch back. This I cut freely with 
Civiale. Immediately following the operation, he ex- 
pressed himself as feeling " like a new man." In his 
written report of the case (he was a physician), he stated 
that, " on the division of the stricture, the relief was 
wonderful!' The discharge ceased within twenty-four 
hours, the perineal pain and frequency of micturition 
and the ardor urinae also ceased, and he returned to 
his hospital duties, which were most active, on the fol- 
lowing day (after having been laid up for over five 
months). The prostate, which I found double its nor- 
mal dimensions on the first visit, is now found to be 
reduced in size fully one-third. The complete cure in 
this case was delayed by repeated recontractions, which 
finally necessitated a division up to 40 f., after which he 
had no further trouble. He was married several years 
since, and now, May 1883, has several children, and is 
in every respect free from his former troubles. It is 
interesting to note that the stream of urine after the 
final operation, was compact and strong, and could be 
propelled easily a distance of three feet. 

Case VI. — Mr. B., aged forty, from early boyhood 
has had more or less irritation of the urethra, usually re- 
ferred to the region of the meatus urinarius. Twelve 
years since, he had an attack of gonorrhoea, which con- 
tinued for nearly a year, in spite of a variety of treat- 
ment. Suffered much during this attack, especially with 
pains in the glan penis. After a continence of several 
months, on having sexual intercourse, found the act of 
seminal emission accompanied by an intense burning 
pain, extending through the perineum and lasting for 
half an hour, described like red-hot lava running over 
a raw surface. On subsequent similar occasions, find- 
ing the same result, his physician being consulted, 
called it a sexual weakness, and treated him by intro- 
duction of bougies. This failing to afford relief, he es 



498 GONORRHOEA AND ITS SEQUELS. 

chewed sexual indulgence entirely. Occasionally noc- 
turnal emissions were accompanied and followed by the 
same pain previously referred to, but less severe than in 
connection. In June, 1873, after seven years of conti- 
nence, he noticed a slight gleety discharge from his ure- 
thra, with pain in the glans penis, aggravated by mo- 
tion, walking, or riding. After a variety of opinions by 
various surgeons as to the nature of his complaint, it 
was finally decided to be a stricture of the urethra, 
and was treated by the semi-weekly introduction of 
bougies. His stricture was supposed to be in the deep 
portion of the canal, and after six months of treatment, 
his urethra was said to have been raised in calibre 
from 8 to 11 of the English scale. He then had an 
attack of acute cystitis, lasting two or three weeks, and 
since that time he has been subject to frequent trouble 
in micturition, frequency, and pain along the urethra, 
especially at the glans penis, and " a feeling of wetness" 
as the patient describes it, " that is depressing in the ex- 
treme." He also had weekly seminal emissions. Ex- 
amination in this case showed full development of penis. 
26 f. defined stricture one-third of an inch from the mea- 
tus. Examination of bladder fails to detect any calculus. 
No evidence of contraction at any other point in the 
urethra with No. 21 f. bulb. I divided the stricture at 
the meatus, and passed 30 f. solid steel sound, easily 
through the urethra and into the bladder. This was in 
July, 1873. The operation was followed by immediate 
relief from pain and frequency of micturition. The 
discharge soon ceased, a gradual improvement took 
place in regard to the pain after emission, for sev- 
eral months, when it began to return, and also some of 
his vesical irritation. Examination revealed a recon- 
traction. of the stricture. This was again divided, and 
the patient soon after wrote me that he had done well 
since the last operation and was entirely relieved of all 
his most troublesome difficulties, but an occasional feel- 
ing of irritation in the perineal region, induced him to 
think that slight recontraction might have again re- 
curred, and he proposed to return at some convenient 
time for examination upon this point. 



GONORRHOEA AND ITS SEQUELS. 499 



LESSON LVIX. 

CLINICAL CASES IN ILLUSTRATION OF REFLEX IRRITA- 
TIONS CONTINUED. 

Case VII. — Irritability of the bladder — Frequent urination — Pain follow- 
ing sexual connection — Feeble stream in urination — All promptly re- 
lieved by division of contracted meatus urinarius — Case VIII. — In- 
complete erections — Involuntary emissions — Premature seminal dis- 
charge cured by division of meatus — Case IX. — Pain in back — Hypo- 
gastric region — Groins— Testicles — Inner side of thighs and knees — 
Also slight accumulation in tunica vaginalis of both sides (hydrocele) 
promptly cured by division of meatus urinarius — Case X. — Retention 
of urine from spasmodic stricture and cystitis — Cured by division of 
meatus and deeper stricture. 

Case VII. — Mr. S., aged forty -five, has had gonor- 
rhoea twice, followed each time by a gleet lasting many 
months, finally cured by introduction of steel sounds. 
He had several attacks of irritability of the bladder 
since first attack of gonorrhoea, and long ago noticed 
that this was affected by the use of any alcoholic stimu- 
lant, and also that he did not completely empty his ure- 
thra after micturition. To effect this, he was in the 
habit of pressing his finger along the urethra, from the 
perineum. Unless he did this, a sense of irritation in 
the canal and a desire to urinate, would come on in a 
few moments. Complained of feebleness in making 
water after a week or two of continence. On having 
connection, the stream was at once greatly improved. 
Any sexual excess was followed by pain in the perin- 
eum. His trouble now thought to depend on spasmod- 
ic stricture, and large sounds advised. In order to ad- 
mit them, it became necessary to incise the meatus. 
This done, 32 f. was easily introduced, but not contin- 
ued as contemplated, as all trouble passed off in a few 
days. A few months subsequently, however, his old 
troubles returned, and were not relieved by the use of 
the sound. At this point he came under my care. 
Penis found to be four inches in circumference, which 



500 G0N0RRHCEA AND ITS SEQUELS. 

would indicate a capacity of urethra of at least 38 of the 
French scale. No. 28 bulbous sound detected contrac- 
tion at the meatus. This was freely divided, with the 
immediate result of relieving the irritation of the blad- 
der, and in a short time pain following connection had 
almost entirely disappeared, and the stream of urine 
was increased in force, and the ability to empty the 
canal much improved. 

Case VIII. — Mr. Z ., aged forty-six. Regular and 
chaste in habits until going to China twenty years 
since. Following the custom of foreigners in that 
country, he indulged excessively in sexual intercourse 
for several years. Had a single attack of gonorrhoea, 
from which he recovered completely in a few weeks. 
For the last few months he has been troubled with 
involuntary emissions as frequently as once a week, 
and latterly, in his attempts at sexual intercourse, he 
has failed, on account of the seminal discharge having 
occurred before the erection was complete. He feels 
quite certain that his genital apparatus is less in size 
than formerly. Examination shows penis of normal 
size, three inches in circumference and three in length; 
some enlargement of the left spermatic veins ; testes 
soft, full size, left largest ; meatus urinarius contracted 
to 22 f. On introduction of the bulbous sound through 
it, as it was quite unyielding, it required some slight 
pressure, a, ndas it suddenly slipped into the fossa na- 
vicularis, a regular spasmodic retraction of the penis 
occurred at intervals of three or four seconds (retrac- 
tion about a quarter of an inch), and continuing dur- 
ing the half minute that the instrument was retained, 
and continuing with rhythmical regularity for three or 
four minutes after its withdrawal. The result of the 
introduction of the sound was repeated several times 
at that sitting, the intervals between the contractions 
gradually lengthening, until an interval of five or six 
seconds occurred, when it ceased. These movements, 
so evidently of reflex origin, suggested the dependence 
of his seminal troubles on the same cause. I therefore 
divided the meatus thoroughly, and introduced thirty- 
one sound without difficulty through the urethra. 



GONORRHCEA AND ITS SEQUELS. 50I 

After the operation, the introduction of the thirty-one 
bulb failed to excite any spasmodic contraction of the 
penis, nor in frequent subsequent experiment was I 
able to reproduce this phenomenon. An immediate 
improvement in the general condition occurred. His 
involuntary emissions ceased without other treatment, 
and in six weeks after the operation he informed me 
that he had entirely recovered his sexual powers. 

Case IX. — I. W., aged thirty-four, came to me in 
September, 1873, complaining of frequent seminal emis- 
sions, one or two every week, pains in the lower part 
of the back, in the hypogastric region, in the groins, 
running into the testicles and extending down the inner 
aspect of the thighs to the knees. He was of chaste 
habits up to some four or five months previous, when 
he became engaged to be married. After this time he 
was the subject of frequent and prolonged venereal ex- 
citement and ungratified desire. In a few weeks, in- 
voluntary emissions became frequent and finally pain- 
ful, with suffering for some time after. Gradually the 
previously described pains of the back, hypogastrium, 
groins, testicles, etc., came on, resisting all treatment 
by his family physician until the present time. I pre- 
scribed for him absolute abstinence from sexual con- 
tact, general care of diet, side position in sleep, cold ablu- 
tions, etc., and a mixture of bromide of potassium with 
the bromide of ammonium and tincture of ergot. De- 
cember 3d, three months after (living several hundred 
miles distant), he came again to see me, with the report 
of an entire relief from the seminal emissions, but had 
had swelling of testicles, and still suffered from almost 
constant pain in the back, over pubes, in the groins, and, 
especially of late, in the testicles, extending down the 
thighs. Examination revealed a serous effusion into 
the tunica vaginalis of both sides ; in the left some three 
drams of fluid ; in the right rather more, and which 
backed well up to the external abdominal ring. The 
light test showed this fluid to be quite transparent. I 
at first thought of treating it as an ordinary hydrocele, 
by withdrawing the fluid ; but on finding a meatus, sit- 
uated on the superior aspect of the glans, contracted to 



502 G0N0RRHCEA AND ITS SEQUELS. 

15 f., and holding the bulb for fully one third of an inch, 
and further finding that he had long been troubled with 
dribbling after micturition, I explained to the patient 
the possibility of all his trouble arising from this con- 
genital deformity. He promptly consented to an ope- 
ration, and I divided the contraction thoroughly, pass- 
ing afterwards a thirty-four steel sound through the 
urethra. (Circumference of penis three and a half 
inches.) Several sensitive points were recognized by 
the patient during the passage of the sound, indicating 
a granular condition of the mucous membrane. Im- 
mediate relief of the pain in the testicles and down the 
thighs followed the operation. Within a month all 
trace of fluid in the tunica vaginalis had disappeared; 
he had had a single nocturnal emission without pain, 
and with the exception of a feeling of nervous anxiety 
through the hypogastrium (which came on occasionally), 
and some pain in his back, after general fatigue, he was 
quite recovered from his troubles. No internal reme- 
dies were made use of subsequent to the operation. 
Subsequently this patient married, had several chil- 
dren, and has continued well up to the present time, 
May, 1883. 

Case X. — Mr. De F., aged forty-three, came under 
my care in March, 1867, suffering from retention of 
urine following a debauch. As no great amount of 
urine was present in the bladder, I gave him mur. tr. 
ferri, advised a hot bath, and left him. On the follow- 
ing morning he expressed himself free from any trouble, 
and declined an examination of the condition of his 
urethra. In December, 1871, he again presented, com- 
plaining of incontinence of urine. He was also suffer- 
ing from intermittent fever (which I suspected was due 
to his urinary trouble.) Said he " made his water freely, 
but could not hold it." I found some accumulation in 
the bladder. As the patient lived out of town, I made 
no examination, but advised him to make arrange- 
ments to come in town on the following day for treat- 
ment. 

He did not present again until November 30, 1872, 
when he came with the statement that he had then lost 



GONORRHOEA AND ITS SEQUELAE. 503 

all control of his urine ; had had none for the past year. 
On the day previous, while riding, he noticed a swell- 
ing in the perineum, and " wished it looked after." 
Examination revealed a firm elevation of the left of the 
raphe, one and a half inches in diameter at the base, and 
about an inch in elevation, extending from just behind 
the anterior border to the anus to the junction of the 
scrotum with the perineum ; solid, resilient and pain- 
less ; no constitutional disturbance ; temperature, 98^-°. 
On examination of the urethra, expecting to find a deep, 
tight stricture, I was surprised to find myself able to 
pass No. 13 f. catheter into the bladder, and to draw off 
a full pint of fetid urine, although he had just urinated. 
During the day the swelling increased, and interfered 
with the calibre of the urethra, so that I could only 
pass a No. i catheter into the bladder, and that with dif- 
ficulty. Attaching this to Dienlafoy's aspirator, I drew 
off a pint and a half of urine. This, on examination, was 
found to be free from any evidence of organic disease 
of the kidney. 

I then incised the tumor down through the superficial 
perineal fascia, and gave exit to a thin layer of pus, in 
quantity about a drachm. 

It was only on the fourteenth day after (the swelling 
gradually subsiding) that urine was found flowing 
through the wound. In the meantime, the patient suf- 
fering from cystitis, his bladder was washed out with a 
double-channeled catheter, No. 20 f., which was passed 
without difficulty, although a perceptible clinging was 
recognized near the meatus. His bladder trouble in- 
creasing so that he made his water every hour, and it was 
loaded with pus. I urged an operation on the stric- 
ture, which, from the easy passage of the catheter, I 
had not before considered of much importance. Intro- 
ducing bulbous sound, No. 20 f., I could not detect any 
stricture ; on it withdrawal it was arrested at a point 
half an inch from the meatus. Incising the stricture 
with the dilating urethrotome, which I introduced 
with some difficulty ; I then passed No. 30 sound, with- 
out obstruction, down into the bladder. On the follow- 
ing day I found that the frequency of evacuation of the 



504 G0N0RRHCEA AND ITS SEQUELS. 

urine had decreased from one hour to six between the 
acts ; that the purulence had decreased, and that much 
less urine flowed through the opening in the perineum. 
From that time the patient continued to improve ; his 
control of the flow of urine was restored ; the purulence 
gradually disappeared, and within a week his perineal 
incision had healed, and he left for his home apparently 
well, not having had any treatment whatever since the 
healing of the wound at the point of stricture. Circum- 
ference of penis in this case, three inches. Up to the 
present time, May, 1883, (eleven years from date of op- 
eration) he has continued well. 



GONORRHOEA AND ITS SEQUELS. 505 



LESSON LX. 

Clinical cases continued — Case XI. — Chronic irritation of the bladder, and 
gleet — Division of stricture followed by complete cure— Patient con- 
tinues, after thirteen years, to be free frpm urinary difficulties — Case 
XII. — Neuralgia of testicles — Spasmodic contraction of the cremaster 
muscles — Pain in the groins, extending to knees and feet — Cured by 
complete division of meatus and deeper strictures — Case XIII. — Irrita- 
tion in glans penis — Gleet — Frequent desire to urinate — Suspicion of 
calculus — None found — Division of meatus urinarius affords prompt 
relief to gleet and to reflex irritations — Case XIV. — Lack of virility — 
Frequent seminal emissions — Imperfect erections — Sense of weakness 
in urethra — Dribbling after urination — Unceasing desire to urinate — 
Cured by division of contracted meatus. 

Case XL — February 12, 1872, Mr. A., aged fifty, came 
under my care, through the courtesy of a professional 
friend, with the statement that he had been suffering 
from chronic irritation of the bladder, accompanied by 
a slight urethral discharge, more or less troublesome, 
for a period of five years. 

He was thought by his physicians to be the subject 
of " gravel," and for a long time had been much treated, 
and was finally sent abroad, in the hope that entire 
change of habit and climate might afford relief. He 
returned somewhat benefited. Soon after (about three 
months previous to his visit to me), and subsequent to a 
a season of prolonged exertion, physical and mental, 
acute irritation of the bladder recurred, with re-estab- 
lishment of the urethral discharge, the latter quite like 
gonorrhoea, and was treated as such, although he had 
lived in the odor of marital sanctity for more than 
twenty years. Anti-blennorrhagics were administered 
with no benefit. Injections afforded only temporary 
relief. 

The patient presented to me in usual general health ; 
digestion good. He gave a history of an attack of gon- 
orrhoea twenty-five years previous, which was treated 
solely by internal remedies. A profuse muco-purulent 
discharge was present. On urination the stream was 



506 GONORRHCEA AND ITS SEQUELS. 

irregular and contracted. Meatus of moderate size, and 
admitted i8f. bulbous sound; this was passed slowly 
and with some pain for half an inch, when it suddenly 
slipped into a capacious urethra beyond. On with- 
drawal, it was firmly held at half an inch from the mea- 
tus. On the same day I incised the stricture freely 
with Civiale's bistourie cache and passed No. 30 f. and 
sent him home with directions to his professional at- 
tendant to have dilatation practiced daily until healing 
of the wound was complete. Returning July 2d, he 
reported himself as having had entire relief from his 
bladder trouble, and from the discharge since the heal- 
ing of the incision. For a few days previously, how- 
ever, he had suffered with some vesical irritation. Ex- 
amination revealed some contraction still remaining on 
the site of the stricture ; this I at once relieved by the 
use of the dilating urethrotome, and passed 30 f. down 
into the bladder. For over thirteen years this patient 
has been free from all urinary difficulties. 

Case XII. — T. W„ aged thirty-five, had gonorrhoea 
fifteen years ago ; has had it several times since. The 
last time, four years ago, coming on forty-eight hours 
from date of exposure. After the discharge had existed 
ten or twelve days, he states that he " stopped it with a 
powerful quack injection.' ' Three or four days subse- 
quent to this he began to suffer with a neuralgic pain 
in the left testicle, the scrotum became tender and red, 
testicles moved up and down alternately much of the 
time, and the penis was greatly contracted ; there was 
likewise pain in the groins, described as drawing and 
sickening, which extended down into his knees and the 
bottoms of his feet. This continued with varying sever- 
ity almost without cessation up to February 22d, when 
he came to New York for treatment. He fell into the 
hands of an endoscopist, who discovered numerous 
granular spots deep in his urethra. Applications made 
at regular intervals for about three months without 
benefit. An application of carbolic acid to the scrotum 
gave some relief to his nervous feelings, but this caused 
vesication, and the relief was but temporary. About 
May 1st, he sought the advice of a surgeon skilled in 



GONORRHOEA AND ITS SEQUELS. 507 

genitourinary diseases. Slight stricture was discov- 
ered near the meatus, and several indurated points far- 
ther down. 28 f. solid steel sound was introduced, and 
after some repetition during one month was given to 
the patient to be regularly used once in three daj^s until 
his trouble ceased. 

Went back to his home, some eight hundred miles 
distant, and pursued the plan laid out for him, but re- 
ceived no benefit. The motion of his testicles was al- 
most constant, and the nervous feeling this induced 
drove him almost frantic. Compared with it the pains 
in his groins, knees, and feet were a positive relief. He 
became very low-spirited and despondent. Early in 
October his physician (who had accidentally met with 
an article of mine in the second number of Dr. Brown- 
Sequard's Archives on " Reflex Irritations of the Genito- 
urinary Apparatus, resulting from Stricture") advised 
him to return to New York and put himself under my 
care. My examination discovered a penis of normal size, 
three inches in circumference ; scrotum greatly relaxed 
and covered with eczematous scales produced by the 
carbolic acid ; testicles hanging very low. My atten- 
tion was at once drawn by the patient to the rhythmical 
contraction of the cremaster muscles, through which a 
see-saw motion of the testicles was kept up, and which 
constituted his chief annoyance. Bulbous sound 30 f. 
passed the meatus, but was arrested at one half inch, a 
point to which his greatest sensitiveness, during passage 
of instruments, had always been referred. Bulb 28 f. 
passes through and detects another stricture at two 
inches, and still another at two and a half. 

On Friday, October 17, at my invitation, the patient 
was examined by Dr. Coldham, of Toledo, Dr. J. De- 
Forrest Woodruff and Dr. Frank Howe, of New York, 
especially in reference to the spasmodic action of the 
cremasters. This was very marked and constant, and 
continued until the patient was placed under the influ- 
ence of ether by Dr. Howe. I then demonstrated the 
size and locality of the strictures before mentioned, and 
divided them in succession with the (my) large dilating 
urethrotome, after which I passed with ease a 30 f. steel 



508 GONORRHOEA AND ITS SEQUELS. 

sound through all and into the bladder. As the patient 
emerged from the influence of the ether, it was ob- 
served that there was no longer any of the spasmodic 
action of the cremasters. When he became conscious, 
he stated that he already felt less of his nervous feelings 
than for many months. He was " certain that the right 
chord had been struck." 

October 8. Improvement continues — no return of 
spasmodic motion. 

October 20. Examination with 30 f. bulb shows a 
slight clinging at one-fourth inch from the external ori- 
fice. Cut this at once, and freely, with straight bis- 
toury, and pass 31 f. The patient, on the following day, 
expressed his belief that a complete cure had been ef- 
fected ; that since the final division of the meatus he 
had not the slightest return of the abnormal sensations 
and pain with which he had, in some degree, constantly 
suffered for the previous four years. Daily introduction 
of the bulb was kept up, in this case, until all bleeding 
ceased, when the patient was dismissed with the prom- 
ise on his part to inform me by post if he had any re- 
turn of his trouble. No such information was received. 

Case XIIL— Mr. H. D., aged fifty-one, had been 
under my professional care for several years ; suffered 
from renal colic on two occasions — once in 1869, and 
again in 1871. Was not conscious of having passed any 
stone through the urethra. Came to me in February, 
1872, complaining of a sense of irritation at the glans 
penis, and a frequent desire to urinate. Careful ex- 
ploration of the bladder failed to discover any calculus, 
but the meatus urinarius was red and tender, and con- 
tracted to 20 f. This contraction was at once divided 
freely ; size not noted. The relief from the irritation 
was immediate and complete. In May, 1873, Mr. D. 
called, stating that his old irritation had returned. Ex- 
amination showed that the meatus had recontracted to 
23. This was again divided, with relief equally prompt 
as on the first occasion ; but in the subsequent daily 
introduction of a glass tube, size, 30 f. an unnecessary 
degree of violence was used by the patient, setting up 
an inflammation, which extended back as far as the 



GONORRHOEA AND ITS SEQUELAE. 509 

prostate, and threatened to culminate in an abscess of 
that organ. This inflammation was accompanied by a 
discharge which did not differ from an ordinary gon- 
orrhoea in the declining stage. After two months of 
treatment the discharge still continued, with more or 
less irritation of the vesical neck. Meatus re-contract- 
ed to 24. Again cut to 30 f. This operation was fol- 
lowed by immediate relief from the vesical irritation. 
The discharge ceased without other treatment, and up 
to May, 1883, the cure has remained permanent. 

Case XIV. — Mr. M., aged twenty-seven, had a his- 
tory of seminal weakness, following self-indulgence from 
fourteen to seventeen. Has never had venereal disease. 
Began to notice a lack of virility a year ago. Seminal 
emissions weekly. Erections imperfect. Frequent de- 
sire to urinate, which is promptly relieved by tr. ferri- 
mur.; but this soon caused constipation (in spite of any. 
thing short of brisk cathartics), and increase of sem- 
inal discharges. Has a constant and annoying sense 
of wetness about the glans. Always dribbles in his 
clothes after urination. Microscopic examination of urine 
shows nothing abnormal but a few shreds of mucous. 
Prescribed mixture of bromide of potassa and bromide of 
ammonium, which arrested seminal emissions for a full 
month. He returned in better spirits. Had much less 
sexual desire than formerly, and occasional imperfect 
erections. Had not been obliged to urinate more than 
three or four times a day, since taking the bromides. 
When he came to me he described the desire to urinate 
as unceasing. After a month he returned with some 
measure of his urinary irritation, although still taking 
the bromides. Great annoyance at the dribbling after 
urination, and says that the constant sense of wetness is 
depressing to the last degree. Examined meatus criti- 
cally ; 30 f. passes, but hugs slightly on return; 31 will 
not pass. Size of flaccid organ three and one-half inches 
in length, and four in circumference. From this I esti- 
mate the normal caliber of the urethra at 38 f. at least. 
As the dribbling seemed to indicate some retention at 
meatus, I concluded to divide it freely. This was done 
without pain, under the influence of local anaesthesia, 



510 G0N0RRHCEA AND ITS SEQUELS. 

when bulbous sound No. 38 f. was passed with ease 
through the length of the urethra, detecting several small 
sensitive granular points in its course. The relief from 
the dribbling in this case was immediate and complete. 
The sense of wetness (as the patient always expressed 
it), which gave him so much annoyance, was completely 
removed. Although taking no internal remedies, he 
has no return of emissions ; the irritation of the blad- 
der also disappeared. In this case the difference be- 
tween 30 f., which measured the size of the evidently 
contracted and unresilient meatus, and 38 f. which was 
easily passed after division of the stricture, viz., eight 
millimeters, showed the extent of the contraction. 

Case XV. — A. W., aged twenty-seven, seventeen 
years ago had first attack of gonorrhoea. Afraid and 
ashamed to speak of it, he suffered greatly for four or 
five months without any treatment whatever. Has had 
several attacks since, which were treated solely with 
injections. About six months ago had an attack of sub- 
acute* prostatitis, which caused him much pain, both in 
urination and defection. This lasted several weeks. 
Since that time he has had desire to urinate more fre- 
quently than natural — several times during the day, and 
also disturbed frequently at night. For the last five 
days he has been obliged to pass water almost every 
hour during the day, and at least every hour during 
the night, suffering great pain in the perineum, also in 
the rectum, at each act of micturition. He has, be- 
sides, a constant desire to defecate. January 10, 1874, 
examination per rectum reveals a tender and enlarged 
prostate, fully double the normal size. External genital 
organs normal, except the meatus urinarius, which was 
contracted to 20. Circumference of penis three and 
one-fourth inches. On passage of 20 bulbous sound, a 
distinct, unyielding fibrous ring was detected, which 
held the bulb firmly at one-fourth inch on its return. 
19 detects second stricture at one inch, and a third at 
one and three-fourths. 

For the patient's immediate relief, half a dozen Swed- 
ish leeches were ordered to be applied to the perineum 
at the anterior border of the anus. Morphia supposi- 

/ 



GONORRHOEA AND ITS SEQUELS. 5 II 

tories every four hours. Under this treatment, with 
rest in bed, the rectal discomfort abated. Frequency 
of micturition, with pain in the perineum and rectum, 
remained without much amelioration until January 
1 6th. On this date the patient was etherized, and with 
the assistance of Dr. Beach Jones and Dr. Weisfelder, 
I first divided the stricture at the meatus freely with 
Civiale's bistonrie cache ; then introducing the small ure- 
throtome, I dilated to 30 f . and cut the second stric- 
ture at one inch ; readjusted and cut the third at one 
and three-fourths, after which 3 1 steel sound was passed 
readily into the bladder. 

The relief from pain and irritation in the rectum and 
at the neck of bladder followed the operation almost 
immediately. By the following day the desire to urin- 
ate was reduced to the normal standard, and the patient 
was disturbed only once during the night. February 
10th, twenty -six days after the operation, he reports 
himself as having no further trouble, and as passing 
his water two or three times during the day and once 
at night. Examination per rectum shows the prostate 
free from tenderness, but fully double its normal size. 
Thirty-one steel sound passes through the urethra 
without the slightest trouble. 



512 GONORRHOEA AND ITS SEQUELS. 



LESSON LXL 

Clinical cases continued — Case XV. — Subacute prostatitis — Frequent 
urination — Pain in the perineum and rectum on micturition — Acute 
enlargement of prostate — Prompt and complete relief on division of 
meatus and deeper strictures — Case XVI. — Frequent and painful mic- 
turition resisting all treatment — Cystitis — Pains in testicles, back and 
abdomen, promptly relieved by division of strictures — Case XVII. — 
Frequent urination — Cystitis — Ordinary treatment ineffectual — Pains 
in hypogastria, thighs, testicles — Immedidiate relief upon division of 
contracted meatus urinarius — Cure permanent. 

Case XVI. — Mr. X., aged fifty-four, seen in consul- 
tation with Dr. Ives, his family attendant. Had a history 
of gonorrhoea twenty-eight years previous ; severe, 
lasting two months. Second attack eight years ago ; 
not severe ; subsiding entirely in ten or twelve days 
under the use of injections of acetate of lead alone. 
Three years ago he began to be troubled with frequent 
micturition during the day and four or five times at 
night, associated with pain extending from the end of the 
penis to the neck of the bladder ; also pain in the tes- 
ticles and perineum, and extending down the thighs. 
Urine occasionally stopped and required to be drawn 
off with a fine catheter. Was taught to do this him- 
self, and has often obtained relief in that way. About 
the first of August last, after using the catheter, he dis- 
covered a small bit of gravel in the eye of the instru- 
ment. Since that time he has voided a large quantity 
of the same sort, with fine, whitish sand, mucus, pus, 
and blood. Was under the care of a prominent sur- 
geon in Brooklyn last summer, who, after careful ex- 
amination, assured the patient that he had no stone in 
the bladder. This surgeon treated him at first by fre- 
quent washings out of the bladder; afterwards he used 
the galvanic current, with one pole in the bladder and one 
on the back. This was continued daily (!) for six weeks, 
but no improvement was manifest, and as the patient 
was much debilitated, he was sent into the country to 



GONORRHOEA AND ITS SEQUELAE. 513 

recruit. Since that time he has had no treatment ex- 
cept the use of Lee's lithontriptic pills, and the use 
of the catheter when required by attacks of retention 
of urine. 

November 24, 1873. Present condition: Is in feeble 
general health. Has an expression of great and con 
stant pain ; is very restless and moans frequently, al- 
though evidently attempting control ; skin pale and 
yellow; says his weight is 130; weight formerly 160. 
Genital apparatus well developed. Right testicle in- 
vaded inferiorly by a mass of fibrous feel, involving 
one-half the body of that organ. Left much the same, 
but softer. Passes urine in my presence in a small, 
divided, uncertain stream. Urine of strong, stale odor, 
thick and muddy in appearance. Albumen present 
in considerable quantity. Cursory microscopic exam- 
ination shows cells of pus and blood. Epithelium from 
urethra, bladder, and pelves of kidneys, but no casts. 
Meatus urinarius apparently normal. Twenty-nine bul- 
bous sound passes to the depth of one-third of an inch ; it 
is, however, abruptly arrested at this point, and only 20 f. 
will pass. This (No. 20) found no farther obstruction in 
the deeper portion of the canal, but, on return, was firmly 
held at three-fourths of an inch, thus defining a stricture 
more than one-third of an inch in breadth. Visiting the 
residence of Mr. X., November 26th, he was found walk- 
ing the floor with constant moans, begging to have the 
operation done at once to relieve his agony. Assisted by 
Dr. Ives, the patient was promptly anaesthetized. The 
stricture near the meatus was then thoroughly divided, 
and No. 30 f. bulbous sound passed through to one 
inch — here it was abruptly arrested ; 24 f . only would 
pass, and was held firmly on return at one and one- 
third inches. I then introduced the dilating urethro- 
tome, turned up to 30 f . and cut ; 30 f . bulb was passed 
down to two inches, where it was again arrested ; 28 f. 
only will pass, and, on withdrawal, is held at two and 
one-fourth inches. Readjusting the urethrotome, this 
band was also divided, when 31 f. steel sound was passed 
without force through the entire urethra. Ferguson's 
short-beaked sound was then introduced into the blad- 



514 GONORRHCEA AND ITS SEQUELS. 

der and thorough search made for stone, but without 
success. Haemorrhage slight, ceasing within fifteen 
minutes after the operation. Dr. Ives remains in 
charge. 

November 29, three days subsequent to the opera- 
tion, Dr. Ives called, reporting that the patient had 
no pains of any kind following the operation, up to 
his visit of yesterday. Under the influence of ten 
grains of quinine and a quarter grain of morphia he 
had slept for six hours, and on waking passed water 
with freedom, with slight smarting, but no pain. After 
this, the intervals between the act of micturition aver- 
aged about four hours. Passed the steel sound 31 with 
ease. Purulence in the urine greatly decreased. 

December 16. Dr. Ives reports Mr. X. as having 
suffered for a day or two past with pain in the penis. 
Purulence in the urine has entirely disappeared ; 30 
steel sound drops through the urethra into the blad- 
der by its own weight. The possibility of slight recon- 
traction of the stricture at the meatus as cause of trou- 
ble was suggested. 

Decembar 23, Mr. X. called with Dr. Ives. He re- 
ports personally that, while he passed his water every 
half hour with great straining and pain before the 
operation, that since then he has not been called to uri- 
nate oftener than once in three or four hours, up to 
within a week since, when it has been once in two 
hours. All the pains in the back and the lower part 
of the abdomen, in the testicles, and extending down 
the thighs, passed off entirely within a few days after 
the operation. During the last ten days he has had 
pain, referred to the vicinity of the prostate, when uri- 
nating, and the stream has been small and weak; could 
void it only by straining. He had himself passed 30 f. 
steel sound the day previous. 

Examination of the prostate, per rectum, reveals no 
enlargement or tenderness ; 30 f. sound passes without 
difficulty into the bladder, except a little hugging near 
the meatus ; 29 f. bulb is arrested at one-fourth of an 
inch, and holds, on return, at three-fourths. I intro- 
duced a straight bistoury and cut through the contrac- 



GONORRHOEA AND ITS SEQUELS. 515 

tions, so that No. 34 f. bulb passed in and out without 
obstruction, to keep this well open until healing is com- 
plete. Entire relief followed. 

Case XVII. — October 9, 1873, I was called to see 
a gentlemen, aged sixty-four, whose general health had 
always been good ; he had lived generously, but regu- 
larly. He stated that for the ten years previous he 
had occasion to urinate on an average every hour dur- 
ing the day, and through the night even more fre- 
quenly ; for the previous six months he was confident 
that he had micturated every half hour, unless some 
necessity prevented, when he always suffered from the 
delay. At no other time had he any pain ; the fre- 
quency of micturition was simply an inconvenience. 
He stated that he had never had any gonorrhceal trou- 
ble. Several years previously he had consulted an 
eminent surgeon in regard to his urinary trouble, and 
was said to have " stricture just beyond the middle of 
the penis." For this he was treated by the occasional 
introduction of bougies for a couple of months, at the 
end of which time, no benefit being apparent, he ceased 
bestowing any attention on the matter. About three 
months previous he began to notice a creamy sediment in 
the urine, which would cling to the floor of the pot de 
chambre. It was not, however, until about three weeks 
ago that he began to suffer actual pain and straining on 
passing his water. To this was soon added pain in the 
testicles, through the liypogastrhun, and also in the perineum, 
and extending down the inner aspect of the thighs to the 
knee. The stream of urine was subject to frequent sud- 
den arrest, and the straining which followed was se- 
verely painful, and pain extended throughout the regions 
previously mentioned. The urine soon became of a 
deep reddish brown color, with occasional strings of 
blood and mucus mixed with the copious creamy sedi- 
ment, which was now persistently deposited. Not- 
withstanding all this, he continued to ride daily, a dis- 
tance of some three miles, to his office. About a week 
since, finding the motion of his carriage greatly aggra- 
vating his penis, he consulted an eminent medical per- 
sonal friend of his, who informed him that he had a 



5 l6 GONORRHOEA AND ITS SEQUELS. 

grave cystitis, and commended him to my care. I 
found him sitting on a hop poultice, which had been 
prescribed for him by his wife's medical attendant (a 
homoeopath), and ascertained that he had been taking 
frequent doses of a homoeopathic preparation of bella- 
donna. 

Present condition: Constitutional disturbance very 
slight, pulse 80 f. temperature 93I. Inspection of urine 
in the the pot de chambre (which was about one-third 
filled, and had been standing for several hours) showed 
a deposit of mucus and pus, stained and streaked with 
blood, fully one and a half inches in depth. Examina- 
tion per rectum determined the prostate to be of even 
less than the normal size, and free from tenderness. 

The introduction of Ferguson's short-beaked sound 
(No. 20 f.) into the bladder was effected with great 
gentleness, with ease, and without meeting with any 
abnormal impediment in its passage. The bladder was 
then thoroughly explored for calculus, but with a nega- 
tive result. Confident, at first, from the history and 
condition of the case, that it would prove to be one of 
stone in the bladder, I had, thus far, only cursorily ex- 
amined the meatus urinarius. Ferguson's sound (No. 
20 f.) had passed through it easily. 22 f. and 23 f. bulbous 
sounds were now passed with ease, but 24 f. was held at 
one-third of an inch. After slight pressure for a few 
seconds it slipped suddenly through a ring of fibrous 
tissue and passed, without obstruction, down to the 
bulbo-membranous junction. The patient was then 
put upon a free use of infusion of tricum repens, and 
suppositories of belladonna and hyoscyamus every six 
hours. 

A subsequent microscopical examination of the urine 
showed pus and blood in abundance, some urethral and 
vesical epithelium ; none from the ureters, or pelves of 
the kidneys ; no casts ; albumen slight ; specific gravity 
10.20. 

On suggesting to the patient that division of the 
strictured meatus was likely to be a necessity before 
much relief would occur, he desired that his friend, Dr. 
J. Marion Sims, should be called in consultation. 



GONORRHCEA AND ITS SEQUELS. 517 

On Thursday, the 14th, after an exhaustive consider- 
ation of the case, Dr. Sims coincided with me as to the 
possibility, nay (in the absence of calculus and prostatic 
disease), of the probability, that the well-defined con- 
traction at the meatus was the original cause of the 
cystitis, and might be justly held responsible for its con- 
tinuance. The operation was at once decided upon, and 
the patient placed under the influence of ether by Dr. 
Harry Sims. I then thoroughly divided the contrac- 
tion — first by the use of Civiales bistourie cache'— -com- 
pleting the division of some remaining elastic fibres 
with a straight blunt bistoury, until the opening ad- 
mitted bulbous sound 31. This was then carried easily 
down to the membranous urethra, without discovery 
of any farther obstruction. The bladder was again 
thoroughly explored for calculus by both Dr. Sims 
and myself. It was found to be much contracted and 
thickened, but contained no stone. 

On the 15th (the day following the operation) I as- 
certained that, since the division of the contraction, our 
patient had not had the necessity of passing his water 
more than once in two hours, and that the pains in the 
testicles, the hypogastrium, the perineum, and down the 
thighs, which had previously been his chief points of 
suffering, had entirely disappeared. There was mani- 
festly less blood in the urine. By the 16th the pus had 
diminished one-half in quantity, the blood had entirely 
disappeared, and the intervals between the acts of 
urination had increased to two hours and a half. From 
this date the only treatment to which the patient was 
subjected was the daily introduction through the mea- 
tus, into and not beyond the fossae navicularis, of a No. 
31 bulbous sound. By the 26th (twelve days from the 
date of operation) the purulent sediment in the urine 
had entirely disappeared ; riding or walking no longer 
gave him discomfort, and he had resumed his business. 
The intervals between acts of urination now vary from 
two to three hours. There is an occasional occurrence 
of spasm during the act, which causes the sudden stop- 
page of the stream, and the urine is voided slowly, and 
with but little more force than before the operation, 



5 18 GONORRHCEA AND ITS SEQUELS. 

but he is not conscious of any other abnormality re- 
maining. He expresses himself as feeling and being ii 
better condition than for years. A few days subse- 
quent to this interview with the patient he went abroad 
to remain during the winter. 



GONORRHOEA AND ITS SEQUELAE. 5 19 



LESSON LXII. 

Clinical cases continued — Cases XVIII. — Chronic inflammation of the 
bladder — Gleet — Resisting every sort of treatment — Neuralgic pains in 
the groins, thighs, and in the perineum — Enlargement and discomfort 
in testicles — Detection of contracted meatus and deeper stricture — Im- 
mediate relief through division of the meatus and stricture — Com- 
plete recovery without other treatment within four weeks — Summary 
of foregoing cases — Explanation of causes which produce reflex distur- 
bance — Manner in which relief is afforded — Method of operation in such 
cases — Results proving the correctness of diagnosis — Urethrismus. 

Case XVIII. — Aaron B., aged sixty-eight. History 
of a first gonorrhaea at twenty-one. Married at twenty- 
seven ; had seven children, and no trouble with genito- 
urinary apparatus until four years ago, when he con- 
tracted another gonorrhoea. This, after a month, sub- 
sided into a gleet, and to this, in about three months 
after, catarrhal cystitis was added. The cystitis re- 
sisted every treatment, and has continued, in a greater 
or less degree of severity, up to the present time. 
About a year since he began to suffer with neuralgic 
pains in the groins and in the perineum, and he ex- 
perienced a very uneasy sensation in his testicles, one 
of which became suddenly enlarged. 

November 26, 1874. Penis only two inches in length, 
flaccid, three and one-fourth in circumference. Meatus 
18 f. Left testicle half usual size; right normal, but 
with a greatly enlarged and soft epididymis, almost 
entirely covering in the glandular structure, and form- 
ing a swelling above it as large as a Madeira nut, and 
described as the seat of long-standing and very trouble- 
some irritation. Some muco-purulent secretion from 
urethra. Has been treated for some time by use of soft 
bougies with pain and no relief. Complains of pains in 
back and groins, extending down along inner aspect of 
thighs; urination every half hour, day and night; 
freshly voided urine, loaded with pus and mucus ; re- 
action alkaline; strong urinaceous odor; no renal 



520 GONORRHOEA AND ITS SEQUELAE. 

epithelium or casts ; albumen slight ; is uneasy and 
restless in manner, and full of anxiety, quite like a con- 
firmed hypochondriac. Examination with i8f. bulbous 
sound detects a stricture at the meatus, extending- back 
for half an inch, after which it slips down the urethra 
without giving evidence of any farther obstruction. 

December 22. I saw the patient in consultation with 
Dr. Willard Parker. Division of the stricture at the 
meatus agreed upon. Ether administered by Dr. 
Charles Turnbull. The stricture at the meatus was 
first divided. Dense cicatrical tissue, extending for 
fully one-half inch. Bulbous sound 32 f. was then 
passed to two and three-fourth inches, when it was ar- 
rested by a second stricture. 29 f. defined its calibre. 
The dilating urethrotome was then introduced, turned 
to 34, and the stricture divided. 31 solid steel sound 
then passed without obstruction through into the blad- 
der. Relief to the neuralgic pains followed the opera- 
tion almost immediately. Within forty-eight hours the 
intervals between the acts or micturition had increased 
from one-half hour to four or five hours. Purulence in 
urine greatly decreased. Irritation in the scrotum 
ceased, swelling of epididymis gradually went down, 
and the patient made a complete recovery, without 
other treatment, within four weeks. 

In the foregoing cases, presenting features more or 
less grave in their conditions and consequences, a point 
of significant interest is common to all, viz., an abnor- 
mal contraction at or near the meatus urinarius, the 
well determined sequel in the majority of instances of 
antecedent inflammatory action. Abnormal spasmodic 
muscular action plays a prominent part in every case. 
Spasm of the urethral walls, of the accelerator urinal 
muscles, of the cremasters, of the vesical neck, and of 
the seminal ducts, etc.; spasm, as in Case X., so firm 
and persistent that the urethral walls finally gave way 
behind it ; spasm that for months resisted the introduc- 
tion of the smallest instrument, as in Case III. ; spasm so 
persistent that the bladder was not allowed to completely 
empty itself for years (as in Cases XVII. , XVIII., and 
XIX.), and thus producing the chronic catarrh, which fin- 



GONORRHOEA AND ITS SEQUELS. 521 

ally became so grave an element in these cases ; spasm, 
as in Case XII., where the testicles played at see-saw for 
nearly three years, and until the poor wretch who 
owned them was driven to the verge of suicide. 

Some one or several of these conditions appear as a 
persistent feature in each. Spasm, a well-recognized 
result of irritation, is equally significant of debility. 
Most of the cases, if not all, were subjects of sexual ex- 
cess. Irritation supervening upon nervous debility, 
spasm naturally results. Irritations which are known 
to give rise to reflex disturbance are not of necessity 
painful irritations, or which by any special sensation 
invite attention at once to the source of trouble. Dr. 
Hanfield Jones (in his work on Functional Nervous 
Disorders, page 704) says : " It seems to be well as- 
certained that unfelt irritation may give rise to very 
various morbid phenomena, affecting both the motor 
and sensory nervous organs. Dr. Brown-Sequard 
maintains that various forms of insanity, of vertigo, 
chorea, hysteria, tetanus, etc., may be due to irritations, 
starting from a centripetal nerve, and frequently slightly 
felt or unfelt, and that the suppression of these irrita- 
tions may promptly cure the patient." He cites a case 
where a married lady suffered for a considerable time 
with a uterine neuralgia, which ceased completely on 
the extraction of a tooth that had not caused any con- 
siderable annoyance. 

In the excellent little brochure on Stricture of the 
Urethra, by Samuel R. Wilmot, London, he says : " It 
is easy to conceive with what ease morbid irritation in 
the urethra may elude detection, and which, though 
slight, may be capable of exciting perfect reflex action, 
particularly in systems of high nervous mobility, and, 
where the slightest irritation exists within the urethra, 
the mere influence of the mind, derangement of the 
digestive organs, and various other remote causes will 
lead to spasm." What, then, in these cases of evident 
reflex nervous trouble, is suggested as the cause of the 
irritation? Division of a contracted meatus, as has 
been shown, relieves the reflex disturbance ; and yet 
simple contraction of the meatus cannot be sufficient to 



522 GONORRHGEA AND ITS SEQUELS. 

produce such morbid nervous actions as cited ; for it is 
well known that congenital contractions at this point 
are frequent, and yet no irritation ensues. In con- 
genital contractions, however, the muscular surround- 
ings of the urethral orifice are in a normally supple 
condition, and able efficiently to play their part in com- 
pletely emptying the urethra after micturition. Let 
this delicate muscular structure become infiltrated with 
plastic material, and the complete discharge of the last 
drops of urine, through its action, is rendered impossi- 
ble. A dribbling after the act is the necessary conse- 
quence, and this is also an unvarying feature in all the 
foregoing cases. It is this inevitable retention of a few 
drops of urine which I believe to be the starting-point 
of the irritation. As time goes on, and the resulting 
plastic exudation becomes organized, cicatricial tissue 
forming and necessarily condensing, a permanent con- 
traction results, which adds to the muscular ineffici- 
ency, especially when it occurs in an orifice congeni- 
ally insufficient. It is this condition which often 
prolongs a gonorrhoea, and is the most fruitful source 
of chronic urethral discharge following a gonorrhoea. 
That the retained urine causes the irritation I am led 
to believe still farther, inasmuch as behind stric- 
tures at the meatus granular spots of inflammation 
occur, sometimes extending throughout the urethra, 
and on relief of the stricture promptly disappear with- 
out other treatment, as in the third case cited. I have 
seen many such. Local points of tenderness were 
present in almost, if not quite all the cases of reflex 
urethral irritation that I have met. 

Then, as the urethral orifice becomes permanently 
contracted and unyielding, a distinct and sudden arrest 
of the stream of urine repeatedly occurs during the 
forcible acts of urination. Is it too much to believe 
that the force of this blow at the point of arrest will 
add to the irritation, and that the effect of its recoil 
should be felt back even to the vesical neck ? It seems 
to me that this may, after long years of such constant 
irritating influence, prove an important element in dis- 
turbing the harmonious action of the complex sensory, 



GONORRHOEA AND ITS SEQUELS. 523 

motor, and sympathetic nerve distribution, in the 
deeper parts 01 the urethra. 

Considering the force and persistence of the spasm 
in certain cases, the idea of its tetanic nature has sug- 
gested itself, induced by pressure and irritation of the 
nerves of the glans, in the cicatricial contraction. The 
treatment of the contractions by complete division, 
resulting in prompt and notable relief in all the cases, 
is equally suggestive of simple mechanical obstruction, 
(causing urinary retention), or cicatricial irritation. To 
be effectual, however, the division must be absolute and 
entire. It is not sufficient that the meatus be enlarged up 
to the normal urethral caliber. The incision must reach 
down through all cicatricial tissue, and so completely that 
the largest sized bulbous sound which can be passed 
through the opening shall pass in and return without 
the slightest sense of resistance. If it is less than this, the 
contraction is absolutely certain to return within a few 
weeks, often within a few days, in spite even of every 
possible effort to keep the parts dilated. Once, how- 
ever, the stricture tissue is completely divided, it is 
then only requisite that the edges of the wound be kept 
asunder by the occasional introduction of a sound, until 
granulation is established throughout its extent. After 
this (if no new inflammatory action is set up) not only 
will no recontraction take place, but the old abnormal 
fibrous material will in time become wholly absorbed. 
This important statement, applying virtually to all 
strictures of the urethra wherever located, I do not 
make without the ability to prove it by the results of 
this plan, as presented in many cases thus treated. 



URETHRISMUS. 

The term spasmodic stricture has usually been applied 
to all temporary contractions of the urethra, which in- 
terfere in any degree with either the passage of instru- 
ments into the bladder, or the voluntary discharge of 
urine from it. 



524 GONORRHCEA AND ITS SEQUELAE. 

As thus understood, it has been described as varying 
in degree from the slight localized muscular spasm, 
which but momentarily arrests the progress of an in- 
going instrument, to the firm, close contraction which 
more or less persistently resists its introduction in 
skilled hands. Or, from that which occasionally dimin- 
ishes the strength and volume of the outgoing stream 
of urine in urination, to that producing complete and 
enforced retention of urine. 

In whatever degree present in any case, it is claimed 
by all authorities to be characterized by its transient 
duration and its ready yielding to simple remedial 
measures. In accordance with this teaching all per- 
manent or habitual interference with urination or with 
the passage of instruments (except in some rare in- 
stances complicated with vesical paralysis), must have 
an organic cause, and depend either upon the presence 
of an intra-vesical growth, an enlarged prostate or a 
true organic stricture. Not unfrequently, however, 
persistent difficulty of urination, and even retention of 
urine requiring habitual use of the catheter, has been 
observed by surgeons, where no proofs of intra-vesical 
growths were present, and where the easy passage of 
an ordinary catheter precluded the idea of enlarge- 
ment of the prostate or of close organic stricture. It is 
also within the experience of many surgeons to have 
seen supposed subjects of close organic stricture placed 
upon the operating table for performance of external 
perineal urethrotomy, and, when fully anaesthetized to 
astonish the operator by permitting the full sized ex- 
ploratory staff to slip easily into the bladder. 

In other cases the entire absence of that peculiar re- 
sistance to the knife, which the experienced surgeon 
recognizes when dividing cicatricial tissue, and the 
failure to locate with exactness the contracted point, 
will suggest to the memory of some that occasional 
patients, perhaps similarly affected, have not escaped so 
easily. It is scarcely an argument against these sug- 
gestions that reports of such cases have not found 
their way into the published records of urethral sur- 
gery. If now it can be proven that purely spasmodic 



GONORRHOEA AND ITS SEQUELAE. 525 

urethral contraction may, and not unfrequently does, 
present all the important diagnostic features of true 
close organic stricture ; and farther, if it can be shown 
that polypoid and prostatic obstruction are often simul- 
ated by a chronic spasm of the accelerator urinae 
muscles — producing obstruction and persistent closure 
of the membranous urethra — then it will be conceded 
that failure to appreciate so important a complication 
will conduce to grave errors in diagnosis, terminating 
possibly in an operation for conditions which exist only 
in the mind of the surgeon. 



526 GONORRHCEA AND ITS SEQUELS. 



LESSON LXIII. 

CHRONIC SPASMODIC URETHRAL STRICTURE. 

Chronic spasmodic stricture — Views of authorities concerning the muscu- 
larity of the urethra — Views of Sir Henry Thompson in 1858 and 1869, 
in regard to spasmodic stricture — Quite at variance — Mr. Erichsen's 
views — Dittel's views favoring the occurrence of spasmodic stricture — 
Dr. Bumstead considers its short duration a diagnostic feature — Drs. 
VanBuren and Keyes coincide with this view — Dr. Stilling demon- 
strates the capacity of the urethra for muscular spasm, at any point in 
its course — The author's claims of a liability to spasmodic closure of 
the urethra at any point in its course and with such persistence as to 
simulate true organic stricture — Clinical cases in illustration. 

Before the muscularity of the urethra was demon- 
strated by Hancock and Kolliker, the presence of an 
organic muscular layer, surrounding the urethra, was 
inferred by such acute observers as John Hunter, 
Everard Home, Lisfranc, Dupuytren, Guthrie and 
others, from the fact, that obstructions to the passage 
of instruments were met at all points in the course of 
the urethral canal, which were of a transient character, 
and that a distinct grasping of urethral instruments 
was occasionally recognized during their passage. In- 
terference with micturition was, however, referred 
more particularly to spasm of the inorganic or volun- 
tary muscles (compressores urethras) which surround 
the urethra, in the membranous portion of the canal, 
and was attributed to the influence of reflex irritations, 
from various sources. The lines which naturally 
separate these two varieties of spasmodic urethral stric- 
ture have not usually been made prominent in consider- 
ing the subject, although the distinct character of each, 
in regard to effect and locality, would seem to render 
it a matter of considerable practical importance. In 
regard to cause > we have the division of Sir Henry 
Thompson,* into those which result from some local 

* Thompson on Stricture of the Urethra, London ed., 1858, p. 130. 



GONORRHCEA AND ITS SEQUELAE. 527 

lesion, which he terms eccentric spasmodic contractions, 
and those in which this is not present or appreciable, 
and which may be supposed to have a centric origin. 
" Among- the eccentric causes," he remarks, " none is so 
common as a partial organic contraction .... acting 
especially in concert with such lesions, is the passage 
of urine over denuded and sensitive surfaces, which 
becomes a still more fruitful cause, if its character be 
altered from those of health in any way. All irrita- 
tions, of whatever nature, within the urethra or in con- 
tiguous parts (such as haemorrhoids or ascarides in the 
rectum), would be included under the head of eccentric 
causes ; while the term centric is made to include men- 
tal impressions, and all such as cannot be referred to a 
definite locality." " The grand distinguishing feature," 
says Sir Henry, " which marks the phenomena (of spas- 
modic strictures), and by which they are contrasted 
with organic strictures, is their transitory character. 

Again, p. 49, op. cit., he says : " Examples of pure 
spasmodic stricture are, without doubt, rare. Still, the 
influence of muscular action upon the urethra being 
considerable, it is important to recognize it in diseased 
conditions of the organ, since it commonly supervenes 
upon and complicates most of them. Indeed, neither 
organic no inflammatory narrowing of the urethra can 
well be imagined to occur without the co-existence, at 
some time or another, of spasmodic action, to some ex- 
tent, in the muscular tissues around." 

The views of Sir Henry Thompson, as above given 
(in 1858), would seem to have undergone some modifi- 
cation, since, in his latest work (" Thompson on the 
Urinary Organs," London, 1869), while admitting 
urethral spasm as a physiological fact, he inclines to 
ignore it as a matter of importance to the competent 
surgeon. Thus, page 38, op. cit., he says of spasmodic 
stricture, " it is an exceedingly useful excuse for incom- 
petence. Spasm may prevent Ihe urine from going outward, 
but I do not know that it ever prevents an instrument from 
going in." Mr. Erichsen, who is also deservedly emi- 
nent as a surgical authority, says : * " From the fact 

* Erichsen's Science and Art of Surgery, London, i86q, p. I. 11a. 



528 GONORRHOEA AND ITS SEQUELyE. 

that a patient will, at one time, pass his urine with the 
most perfect freedom, while if it be rendered acrid by 
drinking- spirits, etc., almost complete obstruction will 
ensue, this tends to prove the existence of occasional 
spasmodic contraction of the canal." In referring to 
the views of Sir Henry Thompson, he says : " While I 
would not go so far as that surgeon in declaring that 
the name (spasmodic stricture) is merely a cloak for 
want of skill, I confess that I meet with spasmodic 
strictures less often than when I entered practice, and 
I believe the same to be the experience of others." 

Dittel * says : " Spasmodic strictures are not gener- 
ally accepted, and yet it cannot be disputed that diffi- 
culties which simulate stricture occur in certain morbid 
conditions and predispositions; they lack only the con- 
stancy." Difficult micturition, strangury, and an alter- 
ation in the stream, were noted by him as resulting" 
from venereal excess, from the acid urine of patients 
suffering from pyelitis, and from the urine of diabetic 
and arthritic patients, and from irritations of the rectum 
also and colon, by worms, excoriations and fissures, 
and also from mental anxiety. He cites an interesting- 
case, where retention of urine resulted, apparently, from 
the latter cause alone, and which, on two occasions, he 
relieved by the introduction of a 25 Charriere catheter, 
after pressure against the anterior face of the obstruc- 
tion (which was at the membranous urethra) for a quar- 
ter of an hour. Dr. Bumstead, in his excellent text-book 
" Venereal Diseases," Phila., 1870, p. 237), accepts the 
frequent occurrence of spasmodic urethral stricture, and 
says of it : " A spasmodic stricture is characterized by 
its short duration. It appears suddenly in persons of 
delicate habit, . . . and as suddenly disappears. Ex- 
ploration of the canal by means of a sound, after the 
spasm has passed, and frequently during its continu- 
ance, shows that there is no organic obstruction." In 
the recent work of Drs. Van Buren and Keyes (" Genito- 
urinary Diseases with Syphilis," New York, 1874, p. 93), 

* Pitha & Billroth's Handbuch der allgemeinen und speciellen Chi- 
rugie. Dritter Band, p. 49, 1872. 



GONORRHCEA AND ITS SEQUELS. 529 

accepting it as frequently resulting from above-men- 
tioned causes, and as liable to occur in the attempted 
introduction of an instrument through the urethra, they 
remark : " It (the instrument) may be firmly grasped 
and held at any part of the canal, but this is more liable 
to occur just as the instrument is entering the membran- 
ous urethra, when its point may be detained for many 
minutes by the involuntary contraction of the cut-off 
muscles (compressors urethra). If the end of the sound 
is held quietly for a few moments against the contract- 
ing muscle, the spasm will yield and the instrument 
pass on into the bladder." 

In comparing the views of these recent, accepted au- 
thorities in regard to the spasmodic urethral stricture, 
it will be observed that all agree as to its frequency, its 
transient character, and its easy management. 

Dittel met with a case where the pressure of the end 
of a catheter for fifteen minutes against the face of a 
spasmodic stricture, at the membranous portion, was 
required before it yielded. Van Buren and Keyes have 
evidently had similar experiences, as they note this oc- 
casional persistence of the spasmodic barrier. Sir Henry 
Thompson inclines to ignore the existence of the spas- 
modic stricture, and attributes to ignorance and incapa- 
city the arrest of an instrument in its passage into the 
bladder, from any cause but an organic one. In this 
Mr. Erichsen seems quite inclined to agree, although 
appreciating the possible occurrence of a spasmodic 
stricture which should be so persistent that it might be 
mistaken for an organic contraction. 

It is not my purpose at this time to discuss the gen- 
eral question of spasmodic stricture. The recent inves- 
tigation of Stilling (coinciding with those of Kolliker) 
would seem to show conclusively that the muscular 
capacity of the urethral surroundings is quite sufficient 
to account for any amount of contraction which might 
be observed at any point. In his own strong language 
(supported by several admirable illustrations of the 
anatomy of the corpus spongiosum urethras) he says : * 

*B. Stilling, Die rationelle Behandlung der Harnrohren Stricturen. 
Erste Abtheilung, p. 9. 



530 GONORRHOEA AND ITS SEQUELAE. 

" the corpus spongiosum is a muscle through which the ure- 
thra runs." Dr. Stilling so demonstrates the muscular 
stricture of this body, that it is at once seen to be an 
easy matter for such a contraction of the muscular 
stricture of the corpus spongiosum to bring a strong 
contracting force to bear upon any part of the urethral 
canal. While thus accepting and claiming the liability 
of the entire urethra to spasmodic closure, which, under 
certain reflex influences, might embarrass, if it did not 
deceive, a well-informed surgeon, I desire to present a 
series of clinical observations, to illustrate the probable 
frequent occurrence of spasmodic strictures at the mem- 
braneous portion of the canal, which present all the 
diagnostic systems of true organic stricture, and which 
cannot, with certainty, be differentiated from organic 
stricture by any of the plans recommended by author- 
ities. 

Case I. — J. W., frontiersman, aged 45, presented 
November, 1874, with a history of first gonorrhoea 20 
years previously, and several subsequent attacks. Five 
years ago began to have difficulty in passing his urine ; 
stream growing gradually smaller, until, after a de- 
bauch, he had complete retention, and was obliged to 
seek relief at a neighboring military post. After 36 
hours' suffering, he was relieved by the passage of a very 
small, flexible catheter, in the hands of the post surgeon. 
After this he submitted to treatment, by gradual dila- 
tation, for several months. He then learned to pass 
No. 12 English soft bougie. From neglect, he has had 
some half a dozen attacks of retention during the past 
year. At last only the smallest instrument could be 
passed by the military surgeon, and he was advised to 
go East and have a radical operation performed, as 
there were no instruments at the post suitable to ope- 
rate upon so small a str/cture. His habit for a long 
time has been to pass his water very frequently during 
the day, in a very fine, irregular stream, and several 
times during the night. Examination : Is of large sta- 
ture, looking like a strong man, who had endured much 
exposure and hardship. Made has water in my pres- 
ence, in fine, short jets, chiefly dribbling. Circumfer- 



GONORRHCEA AND ITS SEQUELS. 53 1 

ence of the penis, three and one-half inches ; size of 
meatus, 23 f. steel sound passed very easily through a 
very sensivive urethra to the bulbo-membranous junc- 
tion, where it was arrested. Gradually decreasing 
bougies were introduced, until finally No. 12 f. passed 
into the bladder, closely hugged in the deep urethra. 
Allowing it to remain for a few moments, I found it 
free. I then withdrew it, divided the contracted mea- 
tus and stricture, extending for nearly half an inch back, 
and passed 34 f. solid steel sound slowly down to the 
bulbo-membranous junction, when it slipped by its own 
weight into the bladder. After the withdrawal of the 
sound the patient passed his water in a full, large stream. 
From this moment he had no further trouble in urina- 
tion, passing his water at intervals of six to eight hours 
during the day, and not at all at night, for the week 
subsequent to the operation, when he left for his home 
in the far West, apparently well in every respect. 

Case II. — Mr. W., age 27, had first gonorrhoea four 
years previous, lasting in acute form for one month, 
and with painless discharge for six months longer. Has 
had frequent returns of the discharge without fresh ex- 
posure ; had been under treatment for close, deep stric- 
ture for the past year, by several surgeons. Passed his 
urine in a small irregular stream, once in two or three 
hours. His last surgical attendant, after two months' 
treatment, by injections and internal remedies, sent him 
to me, not being able at any time to pass an instrument 
into the bladder. Examination showed external organs 
large, meatus contracted to 24 f., red and pouting, and 
bathed in a profuse muco-purulent discharge. Twenty- 
four f. sound is arrested at five inches. Only fine fili- 
form will pass, and that is closely hugged. Three days 
after, pass filiform with ease and follow with No. 10 f. ; 
then, with some effort, with No. 16 f. After this the 
filiform was again snugly held in the membranous ure- 
thra. I divided the stricture at the meatus freely, and 
introduced No. 30 f. steel sound, which passed, literally 
by its own weight, through into the bladder. 

Case III. — W. F., aged 45, had gonorrhoea 25 years 
ago. After five years, having much trouble in passing 



532 GONORRHOEA AND ITS SEQUELS. 

his water, he consulted a distinguished surgeon, and 
was informed that he had a deep organic stricture. 
Only a very small instrument would pass. By gradual 
dilatation, carried up to 14 English, the difficulty of mic- 
turition was then relieved, but would promptly return 
on the discontinuance of its regular use. Had a slight 
urethral discharge, following connection, but usually 
disappearing without any other treatment than the in- 
troduction of the sound. This introduction was con- 
tinued with great regularity for a period of 20 years, 
on an average of once a month. Finally, having some 
misunderstanding with his surgeon, he took his sound 
and went to another, to whom he recounted his experi- 
ence, and requested him to pass the instrument. Meet- 
ing with some difficulty near the neck of the bladder, 
his new attendant took a smaller instrument, then an- 
other still smaller ; and finally, after causing much irri- 
tation and some haemorrhage, he was requested to 
desist. On the day following he came to my office. 
Examination showed a penis four and one-half inches 
in circumference, and an ample meatus. Thirty-four f. 
solid steel sound (22 English ; introduced by my assist- 
ant, Dr. Fox), entered easily and passed, without the 
least force or halting, through the urethra and into the 
bladder. The size of the penis being four and one-half 
inches in circumference, indicated a urethral calibre 
of at least 40 of the French scale, or 23 of the English. 
I then introduced my urethra-meter, closed, to the 
bulbo-membranous junction, turned it up to 40, and 
drew it easily forward to within one inch of the mea- 
tus, where it was arrested, and required to be turned 
down to 34 before it would pass the obstruction. This 
showed a constriction at this point, of the value of six 
millimetres. As the patient objected to any cutting 
operation, the stricture was gradually dilated to 40 f., 
when the discharge ceased, together with all difficulty 
of urination, and after a month the patient passed from 
my observation. 

Case IV. — Mr. F., aged 32 ; gonorrhoea six years pre- 
vious. After three years, had frequent and increasing 
difficulty in urination, which, after an excess, culminated 



GONORRHOEA AND ITS SEQUELS. 533 

in an attack of retention, which, after lasting 24 hours, 
was relieved with a small catheter. Had subsequently 
two or three attacks of the same kind, relieved in same 
way. October 18, 1874, another surgeon, after repeated 
attempts, failed to pass the catheter. I saw him on the 
afternoon of the 20th. He had passed, guttatim, perhaps 
a pint of urine in the previous 48 hours. Bladder three 
inches above pubes ; patient suffering and anxious ; 
slight fever; pulse 90; temperature 101 . I put him at 
once under the influence of ether. Penis three and one- 
fourth inches in circumference (indicating urethral cali- 
bre 32 £), meatus 23 f. Passed 23 solid steel sound 
without difficulty to bulbo-membranous junction, where 
it was arrested. Trying patiently one instrument after 
another, in decreasing sizes, I at last introduced a small 
filiform bougie (No. 8 f. — 1 English), which was closely 
grasped as it passed through the membranous portion 
of the canal. The patient was apparently under the 
full influence of the ether at this time, but the spasmodic 
action of the compressores urethrse was distinctly recog- 
nized. The filiform was hugged at one instant and 
loose the next. I withdrew it and introduced a No. 
10 f. This went in without difficulty. I concluded to 
pass down the staff of Voillemier and rupture, but 
found the screw of the bougie imperfect. I withdrew 
it and attempted to replace it by another. This was 
resisted in its passage, and it was only after a patient, 
prolonged effort that I finally succeeded. I then fol- 
lowed it with the staff, which was closely embraced in 
the membranous portion. I then cut the meatus freely, 
which I should have done before. In very carefully 
passing down the shaft No. 28 f., the largest I had (with 
the intention of driving it in rapidly as soon as the stric- 
ture was reached), without meeting the slightest resist- 
ance, it went squarely into the bladder. Ten days after 
he called at my office, with an account of an attack of 
chills and fever (to which he had previously been sub- 
ject) following the operation, and stated that he " had 
had no urinary trouble since, and could pass a stream 
as large as his finger." In order to test this case (as 
the rupure, if it was such, had been done with 28 f.\ I 



534 GONORRHCEA AND ITS SEQUELAE. 

passed a 32 f. solid sound, which slipped without resist- 
ance through into the bladder. Up to this time (six 
months from the date of operation) he has remained 
perfectly well. 

Case V. — In February, 1874, 1 received a letter from 
a surgeon, asking advice as to the propriety of operat- 
ing with my dilating urethrotome upon a stricture in 
the membranous urethra. " The stricture," he wrote, 
" is seven inches from the meatus. By using a small, 
pointed bougie it can be passed, and then easily dilated 
to 14 of the English scale. In this condition it has re- 
mained for several months. Interference with and fre- 
quency of urination are his chief troubles. The stric- 
ture is to a great extent spasmodic, as, sometimes, it 
will hold a small instrument with great firmness. Some- 
times I have thought there might be the commencement 
of a false passage, the difficulty of getting an instrument 
engaged was so great." I wrote, suggesting the careful 
examination for an organic stricture in the anterior 
portion of the canal, which by irritation, either from 
passage of urine or urethral instruments, might cause 
the deeper trouble. In an answer, a few weeks after, 
he stated that he had found some contraction at the 
meatus and had divided it, but with no effect upon the 
deeper trouble. May 12 he called with his patient. 
Examination showed contraction at the meatus not fully 
divided. Twenty-nine f. only would pass, while the 
normal urethra was at least 31 f. Two other strictures 
were detected, at two inches, with 29 bulb. Twenty- 
nine solid steel sound was readily passed to the bulb, 
and notwithstanding gentle pressure for several min- 
utes against the face of the stricture, it would not ad- 
vance. I then divided the stricture at the meatus 
freely, also the deeper bands, immediately following 
which a 3 1 solid sound passed, without the least resist- 
ance, through into the bladder. 

Case VI. — W. W., a surgeon of this city, aged 62, 
came to me in the evening of December 18th, suffering 
from an attack of retention of urine. He was in a state 
of great nervous excitement, and was bleeding, some- 
what freely, from the urethra, as a result of attempted 



GONORRHOEA AND ITS SEQUELS. 535 

passage of instrument. His history was as follows : 
First gonorrhoea at 19 (1832,) repeated attacks up to 
1857, at about which time he began to experience some 
difficulty in urinating. This, within a short time, be- 
came so marked that he sought assistance from a sur 
geon of great experience and skill. He was found, 
after a careful examination, to have an organic stricture 
at the bulbo-membranous junction, size No. 3 of the 
English scale. During the following three months 
he was systematically treated by the use of flexible 
bougies, until No. 12 of the English scale (17 f.) was 
reached. The solid steel sound was then substituted, 
and he was directed to use it three or four times a 
month, as long as he lived. He did so for a few months, 
and then neglected it for a year ; when, his urination 
becoming very slow and troublesome, he attempted to 
pass his No. 12. He succeeded, by patient effort, in 
making a false passage, but failed in entering the blad- 
der. He then recommenced with No. 2, and dilated 
his urethra gradually, in a few weeks, to No. 12 again. 
The habitual, semi-monthly use of this size was kept 
up for the next 1 5 years, and up to three years since. 
He then increased the interval to one month, until 
finding, after often waiting half an hour at a time, that 
he was obliged to use gradually decreasing sizes, down 
to No. 5, and besides suffering much from frequency 
and urgency in micturition, he became discouraged 
with his efforts, and concluded to do no more, until an 
attack or retention (with which latterly he had often 
been threatened) should occur. In this event, he pro- 
posed to have the canal restored by a cutting opera- 
tion. For the past five years he had suffered with fre- 
quent chills and fevers, which, notwithstanding a full 
treatment by quinine and arsenic, he failed to cure. He 
was habitually passing his water in a small irregular 
stream, every 30 minutes, on the average, during the. 
day, and five or six times during the night. A cursory 
examination showed that there was no great amount of 
water in the bladder. In view of the injury that had 
already been done to the urethra, and the probability 
that there was a fresh false passage, I prescribed tr. 



536 GONORRHCEA AND ITS SEQUELS. 

mur. ferri., in 10 drop doses every hour, a suppository 
of morphia sulph. \ gr., and rest in bed, assuring him 
that there was no serious trouble, and that, in case his 
retention gave him pain during the night, I would at 
once come and give him relief. 

I neither saw nor heard from the doctor until 
Christmas Day, just one week from the date of his pre- 
vious visit. He then presented, in very good general con- 
dition, and stated after leaving me with his retention, he 
went home, passed a good night, and in the morning 
urinated as usual (except in larger quantity), and since 
then had been about as before the attack. He had now 
come to ask an engagement for the radical operation on 
his stricture. 

It was with the greatest reluctance that he consented 
to an examination, on account of his apprehension of 
pain. He was certain of the locality and extent of his 
stricture, and begged that the examination and opera- 
tion should be done both at once, when under ether. 
The circumference of the penis was three and a half 
inches, indicating a normal urethral calibre of at least 
34. of the French scale. Size of meatus, 28 f. I then, 
with assurance of desisting at the least discomfort, 
began the gentle introduction of 28 f. conical steel 
sound. As the instrument passed along the pendu- 
lous urethra, it was distinctly resisted in its advance 
and grasped at a number of points, finally reaching the 
membranous portion. At a moment when his attention 
was purposely distracted from his urethra, I slipped the 
sound easily, and without the least force, through it and 
well into the bladder. The blank astonishment of the 
doctor may be better imagined than described. On the 
removal of the sound (which in the act of so doing was 
closely held), he exclaimed : " So this is the organic 
stricture I have been systematically dilating, and mak- 
ing false passages around, for the last 20 years ! It is 
impossible. Why should my stream be always so small 
and my urination be so frequent? Doctor" (with alarm), 
" are you quite sure that the instrument did not go 
through a false passage and into the abdominal cavity ?" 
I then demonstrated, by means of a 28 f. bulbous sound, 



GONORRHCEA AND ITS SEQUELS. 537 

the presence of a stricture half an inch in length, com- 
mencing at the external opening of the urethra. I ex- 
plained the occurrence of the frequency and difficulty 
of micturition, and the resistance to instruments, by at- 
tributing it to a reflection of the irritation from the point 
of true stricture at the meatus, to the compressores urethra ; 
this, causing a firm, persistent closure of the urethra, at 
the membranous portion, as often and as long as urine 
was brought in contact with it, or instrumental passage 
attempted. In an examination with the urethra-meter, 
I found two more bands of stricture, at two and a half 
inches, of the value of 30 f. It was, however, to the 
single stricture, at the meatus, that I attributed spas- 
modic trouble. 

January 10. — Dr. presented for an operation 

on the anterior stricture. Present, by my invitation, 
Prof. Willard Parker, Dr. Gurdon Buck (to whom the 
patient was professionally well known), Drs. Stimson 
and W. Parker, Jr. The history of the case was re- 
counted, and the difficulty claimed to be dependent 
upon irritation, reflected from the anterior stricture 
alone. Local anaesthesia by the spray of ether was in- 
duced by my assistant, Dr. Fox. I then divided the 
stricture thoroughly, and introduced 34 f. bulbous sound 
through it, and down to the first slight contraction at 
at two inches ; size 30 f. Thirty f. solid steel sound was 
passed easily to the bulbo-membranous junction, when 
it caught, evidently in a false passage ; 28 f ., with slightly 
different curve, was then passed easily into the bladder ; 
30 f., of same curve, followed it without difficulty. 

Up to the hour of the operation, the patient passed 
his water at least every half hour, on the average. Sub- 
sequent to it, he did not pass it for 10 hours, and then 
in full, steady stream. At the end of a month, when I 
saw him, his average interval between the acts of urina- 
tion was eight hours. 



538 GONORRHOEA AND ITS SEQUELS. 



LESSON LXIV. 

URETHRISMUS, OR CHRONIC SPASMODIC STRICTURE, CON- 
TINUED. 

Points in the cases previously cited which prove the possibility of chronic 
spasmodic stricture to simulate true organic stricture — Cases previously 
cited, types of a class — Other means of diagnosis than those previously 
in use necessary to correct appreciation of the nature of urethral ob- 
structions to the passage of instruments — Knowledge of the normal 
capacity of the urethra a prerequisite — Size and condition of the mea- 
tus urinarius essential to be appreciated — Spasm often persists under 
apparently complete anaesthesia — No reliable examination possible 
while anterior strictures are present — No treatment for close, deep 
stricture by operation justifiable until anterior strictures are removed — 
The presence of slight anterior stricture always capable of causing 
spasmodic closure of the membranous urethra — Simulating organic 
stricture. 

There are several points in the foregoing cases (which 
1 think may be fairly claimed as types of a class) which 
coincide with the accepted characteristics of true, deep 
organic stricture, and which, if not appreciated, would 
lead, of necessity, to an erroneous diagnosis, such as 
was originally made in each one of the cases reported. 

1. A gradual diminution of the stream of urine. 

2. Persistent frequency of micturition. 

3. Persistent resistance to the introduction of large in- 
struments in the hands of skilled surgeons. 

4. Distinct grasping of small instruments, and a gradual 
toleration of instruments of increasing size, and, in this, 
so perfectly simulating the behavior of true organic stric- 
ture that the most skilled and learned surgeons have 
been deceived by these conditions. 

5. The persistence, during a long period of years, of 
all symptoms which are recognized by authorities as 
characteristic of organic stricture. 

" The grand distinguishing feature," says Sir Henry 
Thompson,* " which marks the phenomena (of spasmo- 

*Op. cit., p. 140. 



GONORRHOEA AND ITS SEQUELS. 539 

die strictures), and by which they are contrasted with 
organic strictures, is their transitory character." So says, 
in effect, Mr. Erichsen, Dr. Bumstead, Drs. Van Buren 
and Keyes, Drs. Stilling, Dittel, etc., leading teachers 
and authorities in such matters. 

Now, if this is not the fact (and that it is not, the cases 
cited go to prove), it will be readily seen that those sur- 
geons who differentiate organic from spasmodic stric- 
tures by what is claimed to be " the distinguishing fea- 
ture ', viz. the transitory character of spasmodic stricture" 
are liable to fall into the grave error of treating a reflex 
urethral spasm for organic stricture. It is not at 
all likely that the six cases I have reported, in which 
this error was made (in four cases by none who did not 
fully understand and appreciate all the points which Sir 
Henry Thompson and Mr. Erichsen and others so ex- 
plicitly lay down for guidance in such cases), I say it 
is not likely that these are all the cases in which such 
errors have occurred, or are likely to occur. They are 
types of a class, and a large one too, which will necessi- 
tate the acceptance of other means of diagnosis than 
those now in vogue, before such errors can with cer- 
tainty be avoided. First of these, is the necessary 
knowledge of the normal calibre of the urethra, in which 
symptoms of stricture are present ; second, the size and 
condition of the external opening. If the measurements of 
these two points do not completely correspond, there is 
reason to believe that a reflex irritation may be present, 
which has the power of obscuring diagnosis. If there 
is a stricture, at or near the meatus urinarius, acquired 
through a previous gonorrhoea or of congenital origin, 
contact of urine with the sensitive mucous surface 
(which is always present behind such stricture), or con- 
tact of exploring instruments, is capable of exciting a 
spasm at the membranous portion of the urethra ; a 
spasm which will often persist even when the patient is 
fully anaesthetized ; and will continue up to the time 
that a complete division of the stricture is effected. 

It may, I think, be safely claimed that no reliable ex- 
amination of the deeper urethra can ever be made while 



540 G0N0RRHCEA AND ITS SEQUELS. 

a stricture •, or even an erosion* is present in the anterior 
portion of the canal. Inferentially, then, no treatment 
of deep stricture, per se, should be attempted, until the 
complete freedom from organic contraction of the ante- 
rior portions of the urethra, is established. A long- 
series of careful observation of the urethral calibre (by 
the aid of the urethra-meter), have conclusively demons- 
trated a nearly uniform relation between the size of 
the urethra and that of the penis in which it is located. 
As I have stated in other papers on this subject, that 
the circumference of the presenting penis being three 
inches, the normal urethral calibre will correspond to 
30 or more of the French scale ; if three and one-fourth, 
to 32 or more ; if three and one-half, to 34 or more ; if 
three and three-fourths, to 36 or more ; if four, to 38 or 
more ; if four and one-fourth, to 40 or more. 

When the urethra-meter is not available, a urethral 
calibre based upon these calculations may be implicitly 
relied upon, as not over estimated ; on the contrary, it 
will often be found one or more millimetres below. 
Urethral examinations with a bulbous sound, correspond- 
ing in size to the normal urethral calibre, alone can dem- 
onstrate complete freedom from stricture in any given 
case. The presence of the slightest contraction at any 
point may be accepted as capable of producing reflex 
irritation, which may result in spasmodic contraction, 
which shall possess all the recognized characteristics of 
a deep organic stricture. 

^Thompson, op. cit., p. 132. 



GONORRHCEA AND ITS SEQUELS. 541 



LESSON LXV. 

PERSISTENT RECURRING REFLEX SPASM OF THE BLADDER. 

Clinical cases of persistent reflex spasm of the bladder — Disease of the 
spine a possible cause — Clinical case in illustration — Encysted stone a 
cause of persistently recurring spasm of the bladder, and other reflex 
symptoms — Clinical case in illustration — Description of operation for 
the relief of the same — Removal of the stone — Method of operation — 
Favorable results — Rarity of encysted stone — Sir Henry Thompson's 
experience — Contrivance for facilitating examinations of the bladder 
through a perineal opening. 

As introductory to the subject of persistently recurr- 
ing spasm of the bladder, I desire to cite a few in- 
stances, illustrative of some of the possible sources of 
error in the diagnosis and treatment of urinary difficul- 
ties, when this is a prominent symptom. 

Case I. Pott's Disease of the Spine Causing Reflected 
Irritation and Disease of Genito-Urinary Apparatus, and 
Persistent Spasm of the Bladder. — A gentleman sent for 
me to see him, at Lake George, in July, 1874. He had 
been a subject of hip-joint disease in his youth, and he 
was then forty years of age. For the previous fifteen 
years he had been what might be almost considered an 
athlete, having cultivated his muscular power to a very 
remarkable extent, notwithstanding his lameness. He 
had been rowing a certain day, as was his custom, for 
several hours, when he was somewhat suddenly taken 
with a desire to pass water, and this continued at inter- 
vals of half an hour to an hour for several days, at the end 
of which time I was sent for. The urine was normal in 
appearance, with no deposit, and there was some strain- 
ing after micturition. Upon examination of the blad- 
der nothing was found to account for the symptoms. 
The difficulty of urinating continued without cessation 
for two years, except when temporarily relieved by the 
administration of narcotics. At this latter time he had 
come to have a considerable amount of catarrhal in- 
flammation of the bladder, which had come on very 
gradually. He had never had any gonorrhoea, nor any 



542 GONORRHOEA AND ITS SEQUELS. 

other disease of the genito-urinary apparatus. At the 
time referred to, he was seen, in consultation, by Prof. 
Thos. M. Markoe. The patient had some occasional 
discharges of blood after micturition, after which dis- 
charges, he would have relief from the pain which pre- 
ceded these attacks. Having considerable catarrhal 
trouble, and some considerable pus in the urine, it was 
thought probable that he had stone in the bladder. He 
was put under the influence of ether, and examined for 
stone, but with negative results. His difficulty then 
went on increasing, and having found a very large 
quantity of calcareous matter, the idea of calculous 
disease was confirmed, and the supposition entertained 
that possibly the stone was enclosed in a pouch of the 
bladder. The case went on for another year with very 
little change. He was treated with different narcotics 
and sedatives in order to relieve the great irritation, 
which not only was shown in his frequent urination, but 
which extended throughout the urethral canal. 

About the third year of his trouble the late Prof. 
Wm. H. Van Buren saw him with me, and at first was 
of the opinion that he had stone, but this opinion was dis- 
proved by examination, and still his symptoms went on. 
The spasm at the neck of the bladder was then terrific, 
and would occur as often as every ten minutes. His 
life seemed to be one prolonged torture. Sometimes he 
would have an interval of half an hour of freedom from 
pain, but these intervals were by no means frequent. 

Two years ago, three years after the commencement 
of his trouble, making occasional examinations of the 
urine, I found that there was more or less epithelial 
matter from the ureters and from the pelvis of the kid- 
ney. I urged an operation for the stone which I sup- 
posed to be present. Believing this to be the only 
method by which his life might be prolonged, Drs. 
Van Buren, Gouley, and Markoe were called in con- 
sultation, and it was decided to operate, although there 
was very great doubt as to the presence of stone. It 
was hoped that the irritation would be allayed by afford- 
ing free escape to the urine, even if no stone were present. 
The median operation was accordingly performed by 



GONORRHOEA AND ITS SEQUELS. 543 

Dr. Gouley in the presence of Drs. Van Buren, Markoe, 
and myself. Much to our disappointment no stone or 
other foreign material was found After the operation, 
however, he improved somewhat. Although he did 
well for several months, he failed to regain comfortable 
health. For about a year, notwithstanding he went 
through what in any one else might be considered great 
suffering, he was comparatively comfortable. After a 
summer in the country, on arriving home I was sent for 
to see him. I found him exceedingly comfortable. He 
had complete relief from his bladder trouble, and was 
only passing his water once every three or four hours. 
This seemed very strange to me. His wife mentioned 
at the time in a very casual way, that she thought he had 
an extra lump in his back. He assured me, however, 
that it had existed for a very long time. I found, on ex- 
amination, about the region of the seventh or eighth dor- 
sal vertebra, a distinct projection, and it seemed to me 
that it was evidently the result of Pott's disease of the 
spine. He had previously complained of a great deal of 
pain in the back, but it had been located in the region of 
the kidney, and was supposed to be connected with his 
general trouble. I sent at once for Dr. Van Buren, and 
he agreed with me fully in regard to the presence of 
spinal trouble, and it was decided to place him under 
the care of Dr. Charles F. Taylor. Dr. Taylor then 
became connected with the case, and was dcidedly of 
the opinion that it was one for treatment by his method 
of support, and applied an instrument which he adapted 
to the spine. This treatment was continued for some 
months ; but he became very restless and uneasy, and 
his trouble in urination came back. At the time this 
trouble left him the pain which he experienced lower 
down became localized just above the hips in a plane 
with their top. He was finally put upon^ a water-bed, 
but after a month more of trial with the instrument it 
was found impossible to wear it. Just about that time 
a diarrhoea came on, was very profuse and obstinate 
for a week, and ceased apparently of its own accord. 
Then his bladder trouble increased again, and was 
attended with severe spasmodic pains during micturi- 



544 GONORRHOEA AND ITS SEQUELS. 

tion, which pains were mostly situated at the neck of 
the bladder and at the end of the penis. Within two 
or three days before his death he obtained some relief 
to the pains by the application of snow to the end of 
the penis. After a few weeks more of suffering he died, 
apparently from urasmic convulsion. 

A post-mortem examination revealed first a half pint 
of laudable-looking pus in the cavity of the peritoneum, 
which pus was found connected, underneath the sheath 
of the psoas muscle, with two abscesses located upon 
the left side of the spine, in the neighborhood of the 
eighth dorsal vertebra, at which situation the posterior 
surface of the left lung was adherent. This condition 
explained a very distressing cough from which he suf- 
fered during the last few months of his life. The right 
kidney was found to be the seat of cystic degeneration. 
There was no dilatation of the ureter nor any obstruc- 
tion. The left kidney was three or four times larger 
than the right, was the seat of waxy degeneration, and 
the subject of pyonephritis to a very considerable extent. 
A large portion of the kidney was involved in ulcera- 
tion. There was a collection of purulent material which 
extended more or less throughout the calices. The 
bladder was thickened and contracted, but there was 
no evidence of any ulcerative trouble ; there was no 
evidence of any urethral contraction. There was no 
stone in the bladder, but there was an admirable cul-de- 
sac on which to conceal one. One testicle was atrophied, 
the other considerably enlarged, and its inferior portion 
was the seat of a disease the gross appearances of which 
were quite characteristic of tuberculous disease. 

Case II. — Mr. C , a miner, forty-one years of age, 

from Scranton, was sent to me by Dr. M. J. Williams, 
of Hyde Park, Pa., March 2, 1882, with a history of urin- 
ary troubles, dating back to a gonorrhoea some eighteen 
or nineteen years previous. This gave him much 
trouble for several months ; then, after an interval of 
some years, he suffered with other troubles, which were 
considered due to the passage of urinary calculi, and 
he subsequently passed three small specimens per ure- 
thram. Again free from any special urinary trouble 



GONORRHOEA AND ITS SEQUELS. 545 

for several years, he began once more to be afflicted 
with pain in the region of the kidneys, frequent urina- 
tion, and finally inflammation of the bladder and reten- 
tion of urine. He was treated for stricture by dilata- 
tion, and, finally, by divulsion, without benefit. He 
suffered greatly from frequent and painful urination, 
with pain in the glans penis and great irritation in the 
rectum. He was repeatedly examined for stone in the 
bladder, but none was ever detected. For ten months 
previous, his sufferings had been constant and intense, 
passing his urine every few minutes during the day 
and several times during the night, the stream shutting 
off suddenly, as if something had dropped down at a 
certain point in his urination, and closed the vesical 
orifice. Repeated examinations of the bladder failed 
to detect either the presence of stone or a polypoid 
growth. The patient was subjected to all the usual 
and some unusual procedures for disengaging any pos- 
sible hidden or sacculated stone. The prostate was 
slightly enlarged, chiefly on the right side, and this 
was the only abnormal point ascertained about the 
genito-urinary apparatus. 

In view of the history of the case pointing to proba- 
ble stone in the bladder, and the symptoms distinctly 
indicating what seemed to be a movable obstacle to 
urination, such as a polypoid growth within the blad- 
der or an encysted or otherwise hidden stone, an ex- 
ploratory operation was determined upon. On Friday, 
March 10, 1882, the patient was etherized, and the 
median section for stone was performed. Through the 
opening thus secured, the prostate and bladder were 
explored with the forefinger of either hand succes- 
sively, but without finding anything abnormal. The 
examination was repeated by my associate, Dr. Bangs, 
and also by Dr. Williams, of Pennsylvania, who was 
present and assisting in the operation, and with like 
negative results. The bladder was then carefully ex- 
plored with sounds, but no stone was detected. Just 
as we were in despair of achieving any beneficial result 
from the operation, I again introduced my left fore- 
finger to the utmost limit, gaining, perhaps, by urgent 



54-6 GONORRHOEA AND ITS SEQUEL/E. 

pressure, a quarter of an inch in the depth of explora- 
tion, when a soft, apparently pendulous body, about 
the size of an ordinary bean, was felt by the tip end of 
the finger on the left side of the bladder. The condi- 
tions thus appreciated are represented by the accom- 
panying diagram. 




Fig. 13. 

A pair of narrow forceps was then introduced, and 
the supposed tumor was seized in about one-half inch 
grasp, and twisted gently entirely around. As it still 
held, the forceps were disengaged and the finger again 
introduced. The tumor could no longer be felt in its 
former locality, but, on searching the floor of the blad- 




GONORRHOEA ANL ITS SEQUELS. 547 

der, it was again detected, and on introduction of a pair 
of duck-billed forceps, what appeared to be a firm clot 
of blood was removed. This, on examination proved 
to contain a stone about three-fourths of an inch in 
length by one-half inch in breadth and three-eighths in 
thickness. The surface of the apex was smooth and 
light-colored for about one-fourth of an inch, while the 
remainder was dark-colored and rough, apparently 
marking the encysted or sacculated portion, 
as may be seen in the specimen which is here 
presented, as well as in the accompanying 
photograph. 

After thorough irrigation a large, soft 
catheter was introduced into the bladder 
through the perineal opening and left in, the F i G> I4 ._ Ac t- 
proximal extremity of the catheter being fast- UAL SlZE - 
ened into a male urinal. The patient did not experience 
a single unfavorable result. All pain and difficulty about 
the bladder was removed. The urine flowed freely into 
the catheter. There was no rise of pulse or tempera- 
ture. The catheter was removed on the third day. 
On the fourth the patient began to urinate through the 
urethra. On the fifth he no longer passed any urine 
through the wound. A No. 34 French sound was 
passed every other day through the urethra and well 
into the bladder. By the ninth day the wound of 
operation was healed, the urine was free from pus as a 
sediment, every symptom of former troubles had dis- 
appeared, and on the morning of the tenth day he left 
for his home in Scranton, apparently well in every 
respect. Several months after he was heard from as in 
perfect health. 

Encysted calculi are fortunately rare. Several in- 
teresting examples are cited in Sir Henry Thompson's 
recent edition (1880) of his work on " Practical Litho- 
tomy and Lithotrity," page 93 et sequitur. " A calcu- 
lus," he says, " may be altogether contained in a cyst 
in the bladder, a small part of its surface only being 
exposed at the mouth of the cyst." " I had the oppor* 
tunity," he further says, " of watching at University 
College Hospital one example of this, which was once, 



548 GONORRHOEA AND ITS SEQUELS. 






and only once, struck with a sound during life, although 
the sounding was repeatedly performed. ... At death 
the condition described was found, and it was then 
obvious that the chance of striking such a calculus was 
exceedingly remote, and that no operation could have 
removed it." In the present case a distinct click was 
appreciated during exploration of the bladder on two 
separate occasions, in just the locality where the stone 
was subsequently found, but as this could not be re- 
peated, it was referred to some accidental sound outside 
the bladder. The difficulty of thoroughly exploring 
the bladder with the unaided finger became painfully 
apparent in this case, where failure and success in diag- 
nosis was seen to have depended upon but one fourth 




Fig. 15. 

of an inch in the length of the finger. This fact sug- 
gested the desirability of some ready method by which 
the finger might be efficiently supplemented under 
similar circumstances. The accompanying contrivance 
for lengthening the right forefinger may be readily con- 
structed of ordinary copper wire, and will, I think, 
answer the "desired purpose. 

But for the rare fortune of finally discovering this 
encysted stone, in all probability the trouble would 
have been relegated to the list of obscure reflex nervous 
disorders dependent upon urethral, spinal, or rectal 
causes, until a post-mortem examination should have 
revealed the true nature of the difficulty. It must not 
be forgotten, however, that symptoms almost, if not. 



GONORRHCEA AND ITS SEQUELS. 549 

perfectly identical with those of stone in the bladder, 
in certain cases, may arise from reflex causes quite in- 
dependent of the presence of stone in the bladder, free 
or encysted. 

It may not be irrelevant to our purpose here to cite 
a single instance in point, which was published by me 
in the Hospital Gazette of June 22, 1879, but which has 
now the added interest of nearly three years' subse- 
quent experience : 



550 GONORRHOEA AND ITS SEQUELAE. 



LESSON LXVI. 

Clinical case illustrating the influence of spasmodic stricture in produc- 
ing symptoms of enlargement of the prostate gland — Treatment ad- 
dressed to the spasmodic cause successful in permanently curing the 
difficulty — Clinical case illustrating the influence of a contracted meatus 
urinarius in producing persistent spasm of the bladder and urethra — 
Simulating stone in the bladder and disease of the kidney — Eminent 
authorities at fault for more than twenty years — Final relief of spasm 
through division of the anterior contraction — Post-mortem appear- 
ances — Proving conclusively that the difficulty was due solely to the 
influence of a contracted meatus urinarius — Persistently recurring 
spasm of the bladder during a period of over twenty years, resulting in 
thickening of its walls, dilatation of the ureters, and hydronephrosis — 
Death from uraemia— Cause, a contracted meatus urinarius. 

Case III. — Mr. W , sixty -four years of age, came 

under my observation December 25, 1876, with the fol- 
lowing letter from his family physician : " Mr. W is 

suffering from enlarged prostate gland and the symp- 
toms which usually accompany that condition of things, 
and his trouble has been coming on for some time past — 
difficulty in passing urine, pain, and straining, requiring 
use of catheter. Treatment has been : use of catheter, 
warm hip-baths, suppositories of opium and belladonna, 
laxatives, infus. buchu, mur. tr. iron, as the symptoms 
from time to time idicated, with regulation of diet, etc." 
From the patient I gleaned the following : Never had 
gonorrhoea. First trouble of urinary apparatus was 
an attack of dysuria March, 1875, without any apparent 
cause, except, perhaps, drinking largely of carbonic 
acid water ; lasted nearly a day, and passed off without 
treatment. Second, four months after, similar to first ; 
quite well in the interval. Again free for a month, 
when urinations became gradually more frequent dur~ 
ing day, and obliged him to rise four or five times 
during the night ; walking gave him relief. Finally 
had a retention of urine, lasting, with much suffering, 
for twelve hours. Introduction of catheter resisted. 
Dr. Stephen Smith (visiting physician to Bellevue and 



'GONORRHOEA AND ITS SEQUELAE. 55 1 

St. Vincent's Hospitals), who was called in consulta- 
tion, passed a catheter and drew off the urine. From 
this time, catheter used three times in twenty-four 
hours. No urine passed voluntarily ; great urgency 
and frequent agonizing pain before passing catheter ; 
great straining, involving diaphragm and abdominal 
muscles. This condition continued up to the date 
mentioned, December 25, 1876. 

Examination of prostate by me shows but slight, if 
any enlargement. Ordinary catheter passes in without 
force. Urine drawn is thick with pus and mucus. 

Examination of penis : Circumference, 3J inches ; 
meatus, 32 ; size of urethra, 36 mm. from meatus to 
bulbo-membranous junction, as shown by urethrometer. 
Quiet and infus. triticum repens prescribed. January 2, 
careful examination made for stone ; none found. Blad- 
der irrigated with solution of borax twice a day. Ex- 
amination of several specimens of urine showed nothing 
but catarrhal elements. No abnormal condition could 
be detected about the neck of bladder, and yet the 
patient could pass no urine voluntarily, and as soon as 
he made the effort, tenesmus of the vesical neck came 
on, which gave great distress. 

Passing urine every two hours through catheter, 
which he had been taught to introduce. Having seen 
cases of somewhat similar character, and unable to find 
any cause for the trouble, except a spasmodic one, / in- 
troduced with great care, bearing in mind the importance of 
such a procedure in a man of his age, and suffering with 
disease of the bladder, a No. 32 solid steel sound, without 
force, through the entire urethra. I then followed it 
quickly with No. 34, in order to over-distend the mem- 
branous urethra, which I believed to be the seat of the 

trouble. A few minutes after, Mr. W was seized 

with his accustomed desire to urinate, rushed into an 
adjoining closet and introduced his catheter as usual. 
Returning somewhat hurriedly to resume conversation 
thus suddenly broken off, in two or three minutes he 
again felt desire to urinate, and believing that his blad- 
der had been emptied, simply took up the chamber, 
without any idea of urinating, when, to his infinite 



552 GONORRHOEA AND ITS SEQUELS. 

astonishment and delight, he passed with perfect ease 
over a gill of urine. This was the first passed volun- 
tarily since first relieved of his retention by Dr. 

Stephen Smith. From this time Mr. W passed his 

urine without the aid of a catheter, on an average of 
every two hours for the next four days, introducing the 
catheter only night and morning for the purposes of ir- 
rigation. Great and rapid improvement in health and 
entire freedom from straining and tenesmus. 

January 4th. — To carry out the treatment by over- 
distention, more fully, I incised the meatus to 36 mm., 
the pre-ascertained normal calibre of the urethra, 
passed a No. 36 solid steel sound with complete ease 
through the entire urethra and well into the bladder. 

From that time the recover}- from cystitis was rapid, 
and urine was passed voluntarily and in full stream up 
to October 18th (over nine months), when the patient 
called to say that he had remained quite well up to two 
weeks previously, not having in the interval to rise 
during the entire night to urinate ; but that, since then, 
having taken cold by sitting on a cold stone, his urine 
had presented some sediment, and his urination was 
with increased frequency. The only treatment (aside 
from infus. triticum repens), was by introduction of a 
No. 33 solid sound. 

October 19th. — Mr. W called to say that the ir- 
ritation at neck of bladder, and referred to end of penis, 
disappeared at once on introduction of the sound the 
day previous. Intervals of urination increased to be- 
tween three and four hours, rising only once during 
the night. Recovery from the vesical catarrh, which 
was but slight, was complete within the week, and Mr. 
W., who is still under under my observation in a gen- 
eral way, has been entirely well of his urinary trouble 
from that date to the present, over six years. 

In this case, in the absence of any prostatic enlarge- 
ment or discovery of any polypoid growth, the evi- 
dences of hidden stone were most marked until the pass- 
age of full-sized sound, which promptly demonstrated 
the reflex nature of the difficulty. 



GONORRHOEA AND ITS SEQUELS. 553 

Case IV. — Mr. Z , fifty-seven years of age, had 

suffered from frequent, difficult, and more or less painful 
urination for over twenty years. His earliest trouble 
with the genito-urinary apparatus was an acute urethri- 
tis, which soon merging into a chronic form lasted for 
some years, during which he was treated for urethral 
stricture by several surgeons. Subsequently he came 
under the care of a distinguished physician of New York 
City. At this time he was suffering from frequent mic- 
turition and other troubles of the genito-urinary appa- 
ratus, which suggested possible presence of stone in the 
bladder, a search for which proving unsuccessful, the 
patient was referred to an eminent surgeon (this was in 
i860), who also failed to find any calculus, and treated 
him for some time by local and general measures for 
his cystitis, with varying success. The frequent and 
painful urination continued, however, and he came 
under the of care various surgeons, and physicians, 
regular and irregular. He was at one time under the 
care of Sir Henry Thompson of London, who also ex- 
amined him for stone in the bladder, but found none. 
M. Civiale, of Paris, also made a most exhaustive ex- 
amination with the same negative result. The patient, in 
relating his experience with M. Civiale said : "I was un- 
fortunate enough to arrive in Paris just after an important 
personage who had suffered from symptoms of stone, and 
had been examined by many surgeons without detect- 
ing any stone, had been referred to M. Civiale. After 
a long and careful search Civiale found and removed a 
very small, rough calculus. With this success fresh in 
his mind, he examined my bladder with such thorough- 
ness that I was confined to my bed for six weeks after 
— but he found no stone." His frequent and painful 
urination continued unrelieved, and his urine, at times 
bloody and always with more or less pus, was passed 
every hour, or oftener, for several years. Treatment in 
great variety had been used under the advice of emi- 
nent surgeons and medical men of every school. Patent 
medicines, medicinal waters, and spiritualistic agencies 
had all been tried without avail. Everything, he said, 



554 GONORRHOEA AND ITS SEQUELS. 

that had ever been attempted for his relief, instrumen- 
tal, local, or medicinal, had signally failed, and for the 
few years past he had been under the general care of 

Dr. M . His sufferings increased to such an extent, 

that surgical aid seemed imperatively called for. He 
was referred to a surgeon eminent in genito-urinary 
matters, who also failing to find any stone to account 
for the cystitis, treated it by repeated washings and the 
occasional passage of a No. 26 sound into the bladder ; 
which latter procedure, the patient stated, was the only 
thing that had ever been done for him that appeared to 
do him any good. 

After a time his sufferings increased and became 
complicated with malarious symptoms. He was then 
greatly debilitated, and in almost constant suffering 
with his urinary difficulty, when I was called to see 
him. His general appearance was that of a man suffer- 
ing from malignant disease. His urination, which oc- 
curred regularly at intervals of about fifteen minutes, 
was one continued agonizing spasm for about two 
minutes at each act. The spasm, he said, was less fre- 
quent and less severe at night. He complained also of 
severe pain in the region of the left kidney. This, he 
said, he had had from time to time for a long period, 
and surgeons had universally attributed it to the pre- 
sence of a stone in the kidney. Frequent examinations 
of his urine had failed to detect any organic disease of 
the kidney. A large quantity of epithelium from the 
bladder had, at one time, suggested the possibility of 
epithelioma of the bladder ; cancer had also been sug- 
gested. The pains during micturition were always 
referred to the region of the neck of the bladder, pubis, 
and perineum. He had never had any pain in the glans 
penis, nor was his trouble aggravated by motion, or in 
a carriage. He suffered only during urination. He 
had long worn a urinal. Diet, chiefly of milk. On 
December 30, 1881, I was called in consultation by Dr. 
Lewis Fisher, the family physician, and obtained the 
following particulars of the case: On December 31, a 
careful examination failed to discover any evidences of 
organic disease in the thoracic or abdominal regions. 



GONORRHOEA AND ITS SEQUELS. 555 

The penis showed a circumference of three and three- 
fourths inches and a urethral orifice of 25 French. 
Examination with the urethrometer showed a normal 
calibre of 37 French from the bulbo-membranous junc- 
tion to within three-fourths of an inch of the urethral 
orifice, where the canal suddenly narrowed to 26 
French, registering the same to the orifice, where it was 
25 French. The repeated examinations of the bladder 
(some quite recent) by distinguished surgeons, together 
with the entire absence of pain in the glans penis, or 
any sudden stoppage of urine during the act of urina- 
tion, satisfied me that if there was any stone in the 
bladder it was encysted, and probably would not be 
discovered by the use of the sound. The case 
seemed to me one where the spasm of the bladder, 
occurring with great frequency and severity through 
such a long period of time — then over twenty years — 
must have ended his existence long before if due to 
organic disease of the spine or kidneys; and no evidence 
of any organic disease being present, I suggested the 
possibility of the difficulty being in a measure, if not 
wholly, of reflex origin, and due to the irritation of the 
contracted and thickened urethral orifice, and proposed 
to test the truth of it by dividing the meatus so as to 
make it correspond completely with the remaining 
portion of the canal. To this the patient finally con- 
sented. 

Operation, Sunday, January 1. — Patient brought un- 
der the influence of ether by Dr. Bangs. I then made 
a division of meatus and tissues extending three-fourths 
of a inch back, from 25 mm. to 38 mm., and passed a 
No. 37 solid sound well in the bladder without the least 
force. Following this, there was absolute incontinence, 
the urine passing away without pain, and almost with- 
out consciousness. This condition of things continued 
without especial change until Wednesday, the 4th inst, 
when he had some slight power to retain his urine, and 
for the first time a twinge of pain. He remarked that 
the second night after the operation he had the best 
night's sleep he had had for ten years. His habitual 
hypodermic dose of morphia had been omitted up to 



556 GONORRHOEA AND ITS SEQUELS. 

Wednesday, when, in the early evening", an attack of 
the kidney colic (left side) which he had previously suf- 
fered from, came on, and with such violence that Dr. 
Fisher was sent for, and administered ten drops of 
morphia hypodermically. A comfortable night's rest 
resulted. On Thursday morning, the patient appeared 
in good condition, passing urine without pain. Thurs- 
day night he had another attack of pain in the kidney 
requiring another hypodermic injection. Another com- 
fortable night. The next day (Friday) he felt misera- 
bly, little or no appetite, consciousness of desire to 
urinate every half hour, some slight control and some 
pain, now, and for the first time in the history of the case, 
referred especially to the end of the penis. Never before 
had any pain at the head of the penis. The pain, pre- 
vious to operation, was always and solely referred to 
the neck of the bladder. Took no morphia ; staid in bed 
all day. Last night, suffered from pain in head of penis 
whenever he attempted to urinate, but, when he checked 
the effort, the urine would flow without pain. In all, 
had about six attacks of the pain referred to during the 
night. To-day, Saturday, January 7th, feels weak; no 
appetite ; urinates about every half hour. Now, at 1.40, 
has not passed urine for forty minutes. Urine under 
better control. While dressing this morning he had 
two or three slight urinations during the hour, with 
quite sharp spasms of pain in the head of the penis. 
Since then the spasms of pain have been less in degree 
and frequency. Pus and mucus, which heavily loaded 
the urine at the date of the operation, have distinctly 
and steadily decreased up to the present time. Held 
urine for fifty minutes, and then urinated voluntarily 
without pain, but very slowly. After this, passed No. 
37 bulb through the meatus only (and this simply to 
keep it patent), but with less pain than anticipated, and 
less that at any time before. The bladder, which was 
washed out with warm salt water twice a day before 
operation, has not been touched since that date. Ad- 
vise to have this resumed to-day. Milk diet. 

January 8th. — Had a poor night. Frequent and 
severe spasms extending from head of the penis to the 



GONORRHOEA AND ITS SEQUELS. 557 

bladder, was greatly weakened by them ; occurring 
twenty or twenty-five times during the night. These 
lasted two to three minutes, and were always excited by 
the effort to pass water, passing only half an ounce at a 
time. Yesterday, washed out the bladder about 5 P.M. 
with no special effort. This pain in the head of the 
penis is quite new, and was not felt at any time before 
the operation, and not until five days after, when it 
came on suddenly. Much of the increased nervousness 
appears to be due to reaction from morphine. Spasms 
have been less for the last three hours, and has once 
passed water without spasm. Has taken no morphia 
since night before last, when he had ten drops of hypo- 
dermic injection. Now takes an injection of six drops. 
Says that effect of this will last to make him comforta- 
ble until to-morrow. 

January 9th. — Has had a better night, only half a 
dozen spasms. This morning apparently under the 
influence of morphia, most probably urasmia, as he had 
only five drops last evening. Urine quite thick with 
pus, and has passed a full pint since 7.30 this A.M. 
Complains of great exhaustion, but is evidently so ura> 
mic that not much can be inferred from what he says. 
At 2.50, he had a severe paroxysm, about one and a half 
minutes' pain in bladder. At 3.15, another. At 4.30 
Dr. Fisher gave him rectal injection of peptonized beef. 
He continued in somnolent condition, but less pro- 
found. Frequency of urinations as follows, 10.5, II, 
and 11.45, the last being accompanied by great pain. 

January 10th. — Urinated with great pain every hour, 
sometimes oftener. After pain stopped, dropped off to 
sleep, but could be roused easily. Attempted to give 
beef enema, but he refused to have it. 

Died ursemic on the 1 ith. 

Case IV. — A utopsy by Dr. Welch. — By request only the 
abdominal organs were examined. Kidneys. — Both kid- 
neys are enlarged. The fibrous capsule is adherent to the 
surface of the organs. The cortical substance presents 
a grayish, nearly uniform appearance, with little trace 
of the normal markings. The pyramids are in a great 



558 GONORRHOEA AND ITS SEQUELS. 

part encroached upon by the dilated calyces. No ab- 







Fig. 16. 
Outline sketch, from photograph of post-mortem specimen in case of 

Mr. Z. 

scesses are present in the kidneys. The pelvis and 
calyx of each kidney are greatly dilated, and contain 



GONORRHCEA AND ITS SEQUELS. 559 

turbid, ammoniacal urine. The ureters are likewise 
dilated, so that their calibre nearly equals that of the 
small intestine. The walls of the ureters are thickened. 
No obstruction to the passage of urine exists either in 
the pelvis of the kidneys or in the ureters. 

Bladder. — The wall of the bladder is thickened to 
about four times its normal diameter. This thickening 
affects all of the coats of the bladder, but especially the 
muscular tissue. The mucous membrane of the blad- 
der is thickened, and presents in many places, especi- 
ally about the base, slight elevated, grayish, discolored 
patches, such as are seen in the so-called diphtheritic cys- 
titis. The capacity of the bladder is about that of the 
normal organ. Its contents are ammoniacal, purulent 
urine, and a small calculus. This calculus is about an 
inch in length and conical in shape, resembling in form 
somewhat a canine tooth. Such a calculus might have 
been formed in one of the dilated renal calyces. The 
calcalus is apparently of recent formation, being very 
friable and composed wholly of phosphates, without a 
nucleus of uric acid or oxalate of lime, as was shown 
by chemical examination. 

Urethra and Prostate. — The prostate was of about 
normal size and had not occasioned any obstruction so 
far as could be detected. The calibre of the urethra 
seemed normal, presenting no evidences of stricture. 

Spleen. — The spleen is somewhat enlarged and sur- 
rounded by firm, fibrous adhesions. The liver, stom- 
ach, and intestines present no noticeable change. The 
microscopical examination of the kidneys show a marked 
new growth of fibrillated connective tissue, which is 
infiltrated with lymphoid cells. The uriniferous tubes 
are, in places, compressed and atrophied, in places di- 
lated, in places filled with fatty epithelium. 

Diagnosis. — Chronic cystitis with dilatation of the 
ureters, hydronephrosis and chronic interstitial neph- 
ritis. The cause of the cystitis is not apparent." 

We have, then, here conditions which are not ex- 
plained by anything found in the kidneys, ureters, or 
bladder. The cause of the hypertrophy of the bladder 
walls, the dilatation of the ureters, the dilation of the kid- 



560 GONORRHOEA AND ITS SEQUELAE. 

ney, and the interstitial nephritis would have been plain 
had a mechanical obstruction to the flow of urine been 
discovered, but none was apparent : it was certainly 
not in the kidney, ureters, or bladder. At every period 
in the progress of the case, sounds passed easily into 
the bladder. There was therefore no apparent me- 
chanical obstacle in the urethra, and yet the conditions 
were such as to demand a mechanical obstruction to 
the exit of urine from the bladder to account for their 
existence. It appears to me that the only possible so- 
lution of the difficulty is through the claim of a persis- 
tently recurring spasmodic closure of the orifice of the 
bladder, as a result of irritation reflected from some point 
in the urethra. The examination of the urethra on De- 
cember 31st showed a normal urethral calibre of 38 
mm., except at the orifice, where this and one-half inch 
of the canal was contracted to 25 French, thus showing 
an obstruction, practically a stricture of 13 mm. In 
this connection it is interesting to recall the fact that in 
the very early history of the case there was a persistent 
urethral discharge, and that he was treated for urethral 
stricture by several surgeons. 

The possible influence of a contracted meatus urina- 
rius in producing, in certain cases, disturbance more or 
less grave throughout the urinary tract has long been 
known, although not generally appreciated. M. Civiale 
in his " Traite Pratique des Maladies Genito-Urinaires." 
second edition, Paris, 1850, at page 160 says: "That 
which has struck me most forcibly in dividing a mea- 
tus, often only slightly contracted, is the sudden and 
complete change effected in the general condition of 
the patient. The constriction, which seemed hardly to 
impede the flow of urine, is no sooner divided than all 
morbid symptoms vanish — the urethral walls, which were 
rigid, hard, and inelastic, immediately recover the nor- 
mal condition. The bougie, which at first passed only 
with difficulty and pain, slips into the bladder with ease, 
and in five or six days the slight incision at the meatus 
heals perfectly, and the patient finds himself in a state 
so satisfactory that it would be incredible but for the 
fact that the instances are again and again repeated ; an 



GONORRHOEA AND ITS SEQUELS. 561 

effect so prompt, through means of which the signifi- 
cance is plain, shows that the slightest obstruction in 
the urethra is able to produce the gravest symptoms, 
local and general." Again, in 1858, Sir Henry Thomp- 
son^ in the second edition of his work on " Stricture of 
the Urethra," page 249, says : " I have given complete 
relief to distressing symptoms of very long continuance, 
the cause of which was not suspected, by dividing an ex- 
ternal meatus, which nevertheless admitted a No. 6 
English catheter. I have met," he further remarks. 
" with three marked examples of a similar kind, in which 
the very simple operation necessary was followed by a 
complete disappearance of urinary difficulties, which had 
long been regarded as of an extremely obscure charac- 
ter." In 1874 a paper was read by me before the New 
York Academy of Medicine, on " Reflex Irritations 
throughout the Genito-Urinary Tract, resulting from 
contraction of the Urethra, at or near the Meatus Uri- 
narius, Congential or Acquired." In this paper, nineteen 
cases of this kind were cited, in one of which, Case XVII. 
(page 26 of monograph on "Reflex Irritation," pub- 
lished by McDivitt, Campbell & Co., and republished in 
the Charleston Medical Journal and Review, of July, 
1874), in which frequent micturition often years' stand- 
ing, complicated finally by a grave and prolonged cys- 
titis ; this was promptly relieved by the division 01 a 
meatus, which readily admitted the passage of a 23 
French bulbous sound. Further proof of the capacity 
of anterior urethral contractions to induce spasm of the 
urethra and bladder may be seen in my work on 
" Stricture of Male Urethra," second edition, Putnam's 
Sons, New York, 1880, page 301 et seq., and in articles 
on " Urethrismus, or Chronic Spasmodic Stricture," in 
the Hospital Gazette of April 19, 1879, an ^ J une 2 8, 1879. 
In all the cases reported by Civiale, Sir Henry Thomp- 
son, and myself, immediate relief followed division of 
the contraction. 

In the case of Mr. Z , the subject of this report, 

relief to the spasm of the bladder supervened immedi- 
ately, upon the complete division of the contraction at 
the meatus urinarius, followed by the introduction of a 



562 GONORRHOEA AND ITS SEQUELS. 

sound, corresponding in size with the normal calibre of 
the urethra, as previously determined by measurement 
with the urethrometer. How much of this relief was 
due to the passage of the instrument may be a ques- 
tion, but not the least more force was used in its pas- 
sage than in that of an ordinary sound or catheter 
through a healthy urethra, and not the least pain was 
subsequently felt which could be considered a conse- 
quence of this procedure. The only result which was 
in any way different from other cases where a similar 
operation had been performed was the complete incon- 
tinence which followed, and which continued until the 
fourth day, when slight power of retention was also 
accompanied by a slight twinge of pain. The recur- 
rence of the spasm of the bladder soon after, as a dis- 
tinct effect of the sudden advent of the calculus, renders^ 
the estimate as to the permanence of relief to the spasm 
through the operation entirely conjectural. It still re- 
mains, however, that the cessation of painful and fre- 
quently recurring spasm of many years' standing was 
immediate and complete, as a result of the operation, 
and practically so continued until an added mechanical 
irritation within the bladder reinstated it. The proof 
that the spasms which came on on the fifth day after 
the operation procedure were due to the sudden pres- 
ence of the calculus were, first, that it was for the first 
time in the history of the case accompanied by a well- 
defined pain in the glans penis, which persisted until 
the termination of the case; second, that the calculus was 
recent, as indicated by its great friability. Its shape 
contra-indicated its origin within the bladder,but distinct- 
ly pointed to one of the calyces of the left kidney, into 
which it was subsequently shown to fit in the most perfect 
manner. In the absence, then, of any other means explain- 
ing the years of suffering endured by Mr. Z , or any 

other way of accounting for the post-mortem conditions 
presented in his case, it appears to me reasonable to 
claim that the difficulty was of reflex origin, dependent 
chiefly, if not wholly, upon the contracted meatus uri- 
narius, and I think we are warranted in believing that, 
if this condition and its possible effects had been appre- 



GONORRHOEA AND ITS SEQUELS. 563 

ciated at an earlier period in his troubles, years of agoniz- 
ing suffering would have been avoided, and that his life 
might have been saved through an operation, in a sur- 
gical point of view, of the most insignificant possible 
character. In considering the salient features of the 
foregoing cases, which I believe to be typical, it must, 
I think, be admitted that symptomatic evidences of or- 
ganic idiopathic disease of the bladder and prostate, as 
well as of stone or other adventitious material in the 
bladder, should be received with the distinct under- 
standing that such evidences are possibly due entirely, 
or in part, to sources of irritation quite outside of the 
organs apparently the subject of disease. 



564 GONORRHCEA AND ITS SEQUELAE. 



LESSON LXVII. 

DIGITAL EXPLORATION OF THE BLADDER, BY MEANS 
OF AN INCISION THROUGH THE PERINEUM AS AN 
AID TO DIAGNOSIS. 

Digital exploration of the bladder, as an aid to diagnosis in obscure cases, 
recently brought to notice by Sir H. Thompson — The operation not 
a new one — Reference to cases in the author's experience in support of 
this statement — Recent discussion of the subject in the Royal Medico- 
Chirurgical Society of London — No mention made of the possible in- 
fluence of reflex irritation in producing symptoms simulating encysted 
stone and other obscure bladder troubles — Source of such irritation 
frequently referable to disease of the spine, kidneys, urethra, rectum. 
Clinical case illustrative of its source in the kidney — Another case in 
proof of same — Clinical case, showing that enlargement of the prostate 
sometimes exists without the usual prominence in the rectum — Explor- 
atory perineal incision performed — Unfavorable results. 

This subject has been recently brought into a deserved 
prominence through reports of cases, and a discussion 
of its advantages by Sir Henry Thompson. In his 
paper before the Royal Medical and Chirurgical Society 
of London, Jan. 23d, 1883, this procedure is spoken of 
as " a new method of investigating obscure diseases of the 
bladder." It is certainly not new in America. The case 
of obscure difficulty of the bladder related at the be- 
ginning of the lesson on persistent spasm of the bladder, 
is sufficient evidence that it was appreciated here at 
least ten years previous, and even then it was not new. 
In that case, it was proposed by me for the purpose of 
aiding in diagnosis, and after, as was believed, thoroughly 
exhausting all other means of diagnosis, it was con- 
curred in by all four of the surgeons connected with 
the case, all of whom were public teachers of Surgery, 
and three of them occupied the chair of Genito-Urinary 
Surgery in different colleges in New York. It was 
not then proposed or considered as a novelty. Case 
II. was the subject of perineal incision for purposes 
of diagnosis, operated upon by me march 10th, 1882,, 



GONORRHOEA AND ITS SEQUELS. 565 

and an encysted stone discovered in this way and re- 
moved. This case was published in the New York Medi- 
cal Gazette of April 8th, 1882. 

Sir Henry Thompson's first paper on this subject was 
published in the London Lancet, May 6th, 1882, and 
included directions for the performance of the operation 
of digital exploration of the bladder through incision of 
the urethra, thus : " I always adopt the central incision, 
using a median grooved staff, and a long, straight, nar- 
row-bladed knife with the back blunt to the point. 
Having placed the left index finger in the rectum, the 
knife may be introduced, edge upwards, about three 
quarters of an inch above the anus, with or without a 
small preliminary incision of the skin, (I prefer the for- 
mer) until the point reaches the staff, about the apex of 
the prostrate gland, where it divides the urethra for 
half an inch or so, and is then drawn out, cutting up- 
wards a little in the act, but so as to avoid any material 
division of the bulb. The left index finger is now re- 
moved from the rectum, and following, by the groove 
of the staff, slowly passes through the neck of the blad- 
der, as the staff is withdrawn, thus .... when the 
exploration is made as described above, thus. . . . 

" Taking it for granted that the incisions be made, 
which involve only the urethra and not at all the blad- 
der and prostrate, enable the operator to place the last 
joint of his index finger within the neck and thus to 
draw it somewhat towards him, the exploration may be 
made in the following manner. 

" Maintaining his finger at the spot described, the 
operator should stand up at the foot of the table, a little 
to the left of the patient (who is at the lithotomy posi- 
tion), so as to make firm pressure, with the right hand 
above the pubes, the resistance of the abdominal muscles 
being overcome by the ether. He may now easily feel, 
unless the patient be very stout, the opposite side of 
the bladder coming into contact with the tip of his fin- 
ger, and by concerted movements of supra-public-pres- 
sure with the right hand, with slight movements of the 
left index finger in the bladder, almost every portion of 
the internal coat of the latter may be brought under ex- 



566 GONORRHCEA AND ITS SEQUELS. 

amination. If the patient be thin, the proceeding is 
easy ; it becomes less so, in proportion to the depth of 
the perineum and thickenings of the supra-pubic cover- 
ings, both of which are increased by fat. In the latter 
case, aid may be rendered by an assistant, who makes 
firm pressure with both hands ; but the operator should 
also employ, if he can, the concerted movements de- 
scribed." 

To Sir Henry, however, should certainly be credited 
the first description of a systematic and thorough 
application of the conjoined touch, for physical exam- 
ination of the bladder, by means of one finger intro- 
duced through an incision in the perineal urethra and 
pressure over the pubis with the disengaged hand of 
the operator, or both hands of an assistant. In each one 
of my operations, a similar, but less thorough procedure 
was adopted, although no mention was made of this in 
the report of these cases. In the same manner, the con- 
joined touch has for many years been employed by me 
in examination of the prostate and bladder, through 
the rectum, in the position described on page 405 of a 
preceding lesson. 

The prominence given to this matter by presenting it 
as a new procedure appears to me to favor the trial of 
it by surgeons not aware that it has long been considered 
a dernier resort by surgeons experienced in genito-urin- 
ary diseases, and this before due consideration has been 
had for measures greatly less perilous in a surgical point 
of view, and shown to be possibly efficient in clearing 
up a diagnosis in cases which would otherwise have 
been considered suitable ones for the exploratory oper- 
ation through the perineum. The fact that no irritations 
proceeding from disease of the spine, disease of the kid- 
ney, disease of the rectum, or from urethral contractions, 
either by Sir Henry Thompson in his different papers 
and reports of cases, nor by any of the distinguished sur- 
geons who discussed the question in the meeting of the 
Royal Medico-Chirurgical Society, would leave it to be 
inferred that the operation of cutting into the bladder 
through the perineum, for diagnostic purposes, had been 
frequently done without knowledge of the fact, that 






GONORRHOEA AND ITS SEQUELS. 567 

cases presenting all the symptoms of tumor of the blad- 
der, and of stone in the bladder, as well as of deep ure- 
thral stricture, may be and are quite likely to be 
dependent upon irritation reflected from the various 
above-mentioned points, and in an especial manner from 
the urethra, and which, in the latter case, might prompt- 
ly disappear on restoration of the urethra to its normal 
calibre. Reflex irritations, having their origin in a di- 
seased kidney, not differing in the symptoms produced 
from encysted stone or tumor of the bladder, are by no 
means rare. Within a year I have operated on such a 
case by perineal incision. Symptoms of stone had been 
present for nearly two years previous. The most careful 
and often repeated explorations for stone had failed to 
detect anything abnormal in the bladder, and yet there 
was frequent urination, with spasm at the end of the act ; 
pain in the glans penis ; occasional bloody urine and 
chronic vesical catarrh ; all symptoms aggravated by mo- 
tion, especially by riding in a cart. The man appeared 
in florid health for a full year and a half, and then depre- 
ciated, apparently from loss of rest and suffering caused 
by spasm of the bladder, which occurred every few 
minutes night and day. His urethra had been contracted 
congenitally at the orifice. This was restored to a nor- 
mal condition by division, and a full-sized instrument 
passed throughout the entire canal, early in my care of 
the case, but with slight apparent benefit. Finally, I 
made the exploratory incision through the perineum, 
and examined the bladder with my finger. Nothing 
was found in the bladder to explain the source of the 
spasm and other symptoms of stone. 

The operation gave temporary relief to the spasm, 
but death occurred from exhaustion through the pro- 
gress of the disease. The post-mortem examination, 
which was made by Dr. Peabody, Pathologist of the 
N. Y. Hospital, failed to discover any condition of the 
bladder which could account for the troubles so long 
endured. The kidneys were filled with tuberculous deposit. 
There was no evidence of disease at any other point. 

Again, within the last month, the exploratory perineal 
incision was made in a case which for several 3-ears had 



568 GONORRHOEA AND ITS SEQUELS. 

presented symptoms of stone in the bladder, viz., fre- 
quent painful urination, vesical catarrh. Trouble aggra- 
vated by riding or any jarring motion ; pain at such time 
referred especially to a point on the right side of the 
vesical neck. This was very marked when stepping off 
from a chair. Several surgeons, who had had him in 
charge, favored the idea of encysted stone, as a probable 
cause of the difficulty. This was my own opinion when 
three months since I first examined the case. Repeated 
careful exploration for stone gave only negative results; 
after careful consideration, and finding no source of 
possible reflex trouble in the urethra, and failing to obtain 
any evidence of disease of the kidneys, or spine or rectum, 
I proposed the exploratory operation. Dr. Edward L. 
Keyes was then called in consultation, in the course of 
which an examination was conducted with great care by 
sounds, and through the rectum and abdomen by the 
conjoined touch. Nothing abnormal was discovered, 
except a tender point corresponding to the vesical orifice 
of the right uretur, just the point to which the patient 
had referred his chief pain when jolted in any way. This 
was distinctly made out by means of a finger in the 
rectum and pressure with the opposite hand over the 
pubis, the position of the patient being that described 
on page 405. 

A series of analyses of the urine was then suggested, 
before and after exercise, and also subsequent to a rest 
of several days in bed. After some two months of ob- 
servation of the case, finding no evidence of disease 
of the kidney, and finding also that exercise always 
increased the amount of pus in the urine and that pain 
and pus were distinctly lessened by rest on the back, 
and that the tenderness at the mouth of the right ureter 
persisted ; and moreover, that the difficulty was now so 
great that the patient could no longer attend to his 
business, though he was otherwise apparently in good 
health, Dr. Keyes coincided with me fully in the opin- 
ion that the exploratory perineal incision was now de- 
sirable. Just at this time the urine presented for the 
first, a very few hyaline casts. Believing, however, that 
under existing symptoms this was but an evidence of 



GONORRHOEA AND ITS SEQUELS. 569 

increasing trouble from the bladder irritation, the op- 
eration was performed. The result of the exploration 
through the perineal incision was absolutely negative. 
Both Dr. Keyes and myself made the most careful ex- 
ploration of the bladder 'and especially of the point 
where pain had been previously complained of. Noth- 
ing in the least degree abnormal was detected, except- 
ing perhaps some peculiar thickening of the bladder 
wall anteriorly near the neck. Nothing was found at 
point of previous tenderness. The operation gave re- 
lief to the spasm as long as the urine was passed through 
the wound, but whenever any passed through the 
urethra, a severe vesical tenesmus resulted. Unfortu- 
nately, a tube into the bladder through the wound re- 
quired removal on the fourth day on account of irrita- 
tion evidently caused by it. The wound (May 28th, 
thirteen days from date of operation), remained pervi- 
ous. If the patient was careful not to strain, the urine 
flowed through the wound, and he was comparatively 
free from pain, free from fever, and gaining strength. 
What the final effect of the operation may be, it is diffi- 
cult to state, but the prospect is not flattering, especially 
as now, nearly two weeks since the operation, granular 
casts are becoming frequent in the specimens of urine 
examined. 

The probabilities in this case appear to be that the 
bladder trouble is mainly, if not purely, of reflex origin, 
and that the kidney is in some way the source of the 
trouble. 

Not only may the bladder trouble be found in many 
cases to be due to reflex irritation from some point in 
the kidney, urethra, the rectum or the spine, it may also 
be the result of enlargement of the prostate, this last 
even giving no positive result through a rectal examina- 
tion, or through the urethra, and completely simulating 
an encysted stone or a tumor, or even a moveable poly- 
poid growth within the bladder, as in the following 
case : 

Patrick Costigan ; Charity Hospital, admitted De- 
cember 2d, 1882; first difficulty, a retention of urine 
occurring suddenly, about three years before, after a 



570 GONORRHOEA AND ITS SEQUELS. 

drinking bout ; he was relieved by catheter. No fur- 
ther trouble until July, 1882, when he noticed that occa- 
sionally, during urination, his stream would be suddenly 
arrested, but without pain, and after a few minutes, 
would again flow. This difficulty continued and in- 
creased. He described the sensation to be as if a for- 
eign body was floating about in his bladder, and when 
he attempted to urinate this would suddenly drop down 
and stop the passage. Examination with the sound 
gave only negative results ; the straight soft catheter 
passes without hindrance into the bladder ; urine highly 
ammoniacal, but contains neither pus nor other or- 
ganized elements. Is unable now to pass any urine 
without the aid of a catheter. Examination of the 
urethra shows no evidence of constriction. The canal is 
34 f. throughout. Examination per rectum showed ap- 
parently but little enlargement of the prostate and this 
appeared to merge into the bladder walls, so that its exact 
limits were not easily distinguishable. The abdomen 
was protuberant, from accumulation of adipose tissue, so 
that nothing could be ascertained through the rectum 
by the double touch. A soft catheter was passed into 
the bladder and to measure its capacity, sixteen ounces of 
water were injected, but not a drop could be voluntar- 
ily expelled by the patient. On passage of the catheter 
to a distance of eight and a half inches, the urine flowed 
freely through it, and sixteen ounces were returned. \ 
felt satisfied that the obstruction was movable within 
the bladder, and was probably a polypoid growth, and 
after repeated efforts to seize it with the lithotrite, and at 
the earnest request of the patient, an exploratory incision 
was made through the perineum into the membranous 
urethra, and my finger was inserted. The perineum was 
quite deep. After a brief examination, I recognized the 
fact that my finger could just reach the superior border 
of an enlarged prostate which had pushed up into the 
bladder as shown in the accompanying sketch, the lateral 
lobes, falling together on the slightest attempt to urinate, 
formed a valve, which perfectly prevented the exit of 
even a drop of urine, but did not prevent the easy intn> 
duction of a soft catheter. I searched with various in- 



GONORRHCEA AND ITS SEQUELS. 57 1 

struments, still hoping to find a polypoid growth or some 
other cause of obstruction to passage of urine, but ex- 
ploration failed to elicit any cause of trouble beyond the 
valvular obstruction caused by the enlarged prostate 
gland. A soft rubber tube was inserted through the 
wound and prostatic urethra, to just within the bladder 
and tied in. The patient did perfectly well until the 
seventh day, when the wound began to assume an un- 
healthy appearance, apparently from irritation caused 
by the tube ; this was removed. Spasms of the bladder 
occurred on subsequent efforts at urination and required 
free use of morphia to control. Urine drawn through 
catheter, introduced through perineal opening, gave 
only temporary relief, a very slight accumulation of 
urine producing desire to urinate, and spasm of the 
bladder resulting. Partial suppression of urine occurred 
on the twelfth day, and he died ursemic on the four- 
teenth day after the operation. 



572 GONORRHCEA AND ITS SEQUELAE. 



LESSON LXVIII. 

Post-mortem appearances in the foregoing case — Diagram in illustration, 
showing position and probable influence of the prostate; also the size 
and location of a cyst of the bladder which was present — The case cited 
to show that explorations of the bladder through the urethra and rectum 
do not always indicate conditions in which exploratory operations 
through the perineum will be of service — Also to show that result of 
such exploration is sometimes grave, under apparently favorable con- 
ditions — Differences of opinion as to the safety of the operation — 
Operation not essentially different from the median operation for stone; 
as a rule equally perilous — Claim of Sir H. Thompson that it is simi- 
lar in gravity with external urethrotomy combatted; reasons given for 
this opinion — Too favorable statements liable to lead to grave errors 
in practice — Statistics reported by Sir Henry Thompson; proportion 
of cases of exploratory operation where no cause of trouble was found. 
Cases which improved without ascertained reason, suggestive of a reflex 
origin of the original trouble — Idiopathic cystitis rare; in the author's 
experience, always due to mechanical or reflex influences, or extension 
of inflammation from urethra or ureters — Cases in the author's expe- 
rience in illustration of this point — Necessity of examining all points 
capable of inducing reflex trouble in the bladder, before deciding upon 
an exploratory operation through the perineal incision — A full under- 
standing by the patient of the nature and risks of the operation desir- 
able before operation — Under proper conditions, the operation of 
perineal incision and digital examination of the bladder of great prac- 
tical value. 

The report of the post-mortem examination made by 
a member of the pathological staff of Charity Hospital 
and extracted from the Hospital records is as fol- 
lows : — 

u * * * # Ureters, bladder and posterior half of 
the penis removed en masse, together with a fluctuating 
cyst about the size of a large orange. 

" The wound of operation presents a sloughy appear- 
ance and is covered with diphtheritic membrane (so 
called). 

" The Prostate is very little enlarged, but the pros- 
tatic urethra is encroached upon by a bulging inward 
of the lateral halves of the prostate, and which protrude 
into the bladder. 

" The Bladder is contracted, its walls about half an 



GONORRHOEA AND ITS SEQUELS. 



573 



inch in thickness ; its internal surface prominently 
trabeculated, in several places, presenting small sacculi 
of the mucous membrane. The crests of the trabecular 
are everywhere covered with a thick, yellowish-gray 
membrane ; about an inch above the orifice of the right 
ureter is an opening (24 millimetres circ.) into the cav- 




Sketch showing peculiarity of prostatic hypertrophy and vesical cyst. 

ity of the cyst before mentioned, which contained 
about ten ounces of strongly ammoniacal urine. The 
walls of this cyst are one-eighth inch in thickness ; the 
mucous membrane lining them being continuous with 
the mucous membrane of the bladder. * * * 

" Ureters. The right is largely dilated and courses be- 



574 GONORRHOEA AND ITS SEQUELS. 

hind the cyst; the left is but moderately dilated. Both 
show evidences of acute inflammation. * * * " e tc. 

This case is cited chiefly to show that diagnosis by 
symptoms and by examination of the bladder with 
sounds, and also through digital exploration through 
the rectum will not afford positive information as to the 
cases which will be relieved through the exploratory 
perineal incision, and those that will not. 

It shows also that there are cases where, on account 
of the enlargement of the prostate, the digital examina- 
tion of the bladder, through the exploratory perineal 
incision, is impossible. It also shows that the operation 
for purely exploratory purposes, is occasionally fatal in 
its immediate results, and that, with the patient in fair 
condition, and presenting in life no positive evidence of 
any organic disease. I quite agree with Sir Henry 
Thompson that the operation is a simple one, easily and 
readily performed ; but that it is, as he has stated, only 
an external urethrotomy involving neither the prostate 
nor the bladder, it seems to me difficult to accept. The 
operation does not differ in any essential particular from 
the perineal lithrotrity of Dolbeau, and but slightly and 
not essentially from that of the median operation for 
stone ; nor do I think that it can be shown to be in any 
way inferior to that operation in point of risk to the pa- 
tient. 

In Sir Henry Thompson's first paper in the London 
Lancet, on this subject, May 6th, 1882, after a descrip- 
tion of the mode of examining the bladder through the 
perineal incision, which is most complete and admirable, 
he claims justly for it the merit of being our most val- 
uable aid to diagnosis in cases of obscure bladder trou- 
bles ; " This being so," he asks, can digital exploration 
of the bladder be performed without much risk to the 
patient ?" he replies, " I unhesitatingly answer in the 
affirmative," and cites cases of Sime's operation for deep 
urethral stricture, as parallel, and supporting his state- 
ment. The operations are quite different. In the case 
of simple perineal urethrotomy, no violence is done to 
the prostratic urethra, the prostate or the vesical neck ; 
they are virtually untouched. In case of digital exam- 



GONORRHOEA AND ITS SEQUELS. 575 

ination of the bladder through the perineal incision, the 
important part of the risk lies in the necessary disten- 
sion required to force the finger onward to its fullest ex- 
tent, and often with much urgency. In order to make 
an efficient examination of the bladder, through the 
method described by Sir Henry, even if a complete 
failure, such as must, with necessary uncertainties of 
diagnosis frequently occur, the operation is never less 
important than that for stone, where no stone is found. 

Assurances as to the safety of such operations, based 
on statistics of external urethrotomy, appear to me likely 
to lead young surgeons into the possible error of resort- 
ing to such a method of diagnosis, before exhausting all 
known rational modes of relief, involving less peril from 
surgical interference than the operation of dividing the 
urethra in the membranous portion, and introducing the 
finger fully into the bladder. With all the knowledge, 
experience and skill of Sir Henry Thompson, in three 
out of four of his first list of cases of exploration of the 
bladder, reported in the Lancet, May 6th, 1882, he failed 
to find any reasonable cause for the trouble. In his list 
of fourteen similar explorations, reported in the Lancet 
of Feb. 10, 1883, he failed, in the same manner in seven. 
Few surgeons, indeed, could hope for anything like the 
good fortune of discovering ioreign bodies in eight 
cases out of eighteen, and relieving them from troubles 
which otherwise must have caused a fatal issue. And 
then, quite a large proportion of the remaining ten 
cases were relieved by the operation without anyone 
quite understanding the reason for such improvement. 

May it not be wise, in considering this curious fact, to 
revert to the case of spasmodic stricture of seventeen 
years duration, whose troubles were not relieved until 
the forcible distension of the membranous urethra ? 
and also to the case, where the difficulty produced pro- 
found bladder trouble, and which was repeatedly, and 
promptly, and finally permanently relieved by over dis- 
tension of the membranous urethra ? And also, the case, 
where the most eminent genito-urinary surgeons in 
America, in Great Britain, and in France had repeatedly 
examined for stone, and for tumor at intervals, during a 



576 GONORRHCEA AND ITS SEQUELS. 

period of over twenty years, and had failed to find 
any, and where, finally, the only cause for the great 
and prolonged suffering, terminating finally in death, 
was a chronic spasm of the bladder, and the cause 
for which no explanation could be found, except a 
contraction of the urethra, within an inch of the ex- 
ternal orifice ! 

It is a practical point of much value to appreciate the 
fact that idiopathic cystitis ever occurring is very rare. 
In my experience it is always the result of extension of 
inflammation in the urethra, or from some mechanical 
irritation within the bladder, or from reflex irritation 
from some point outside the bladder, such as would be 
afforded by stricture of the urethra at some point, or 
from disease of the spine, kidneys, or rectum. 

With such facts as these, and many more equally 
significant of the dependence of obscure bladder troubles 
or reflex irritations outside of the bladder, which cannot 
be doubted, may it not, then, be reasonably asked of 
surgeons everywhere, that in every case of obscure 
bladder trouble, the urethra shall be explored with the 
understanding that any contraction of its calibre, con- 
genital or acquired, including all contractions at the ure- 
thral orifice, shall be accepted as a possible cause of the 
trouble, and removed before deciding upon the perform- 
ance of the external perineal incision, and the introduc- 
tion of the finger through it into the bladder for the 
purpose of aiding the diagnosis. 

While I have not had anything like the proportionate 
success which has fallen to the lot of Sir Henry Thomp- 
son in discovering foreign bodies through the explora- 
tory operation, so warmly advocated by that distin- 
guished surgeon, I have yet had sufficient to make me 
resort to it in circumstances under which I have already 
recommended and performed it, viz., where through 
careful, intelligent and patient examination, every sus- 
pected reflex source of trouble had been, as far as pos- 
sible, removed, and where, with a full understanding of 
the possible advantages and of the necessary doubts of 
success in the search, and the surgical risks of the oper- 
ation, the patient consented to its performance. I am 



GONORRHOEA AND ITS SEQUELS. 577 

also fully persuaded that while the risks of the opera- 
tion of exploratory perineal urethrotony are identical in 
theory and practice with median lithotomy, the opera- 
tion is of great practical value, and a justifiable one 
under proper circumstances. 



INDEX. 



Abscess of inguinal glands, 31 
" perineal, 370 
" prostatic, 408 

Brain lesions of syphilis, 199 

Balanitis, 353 

Balano-posthitis, 353 

Bubo, diagnosis and treatment of, 

250 
Belfield on the parasitic origin of 

gonorrhoea, 275 
Barker on the nature of gonorrhoea, 

273 
Bassereau on chancre and chan- 
croid, 211 
Beisiadecki on microscopical ap- 
pearances of chancre, 29 
Beale on the origin of syphilis, 19 
' ' on the vitality of animal cells, 

36 
" on disease germs in gonor- 
rhoea, 269 
Bumstead and Taylor on abortive 
method of 
treating 
gonorrhoea, 
298 
" onthe nature 
of gonor- 
rhoea, 272 
" on gleet, 338 
" onconta- 
giousn ess 
of late le- 
sions, 170 
" on syphilitic 
d ac tylitis, 
188 
Baumler on contagiousness of late 
lesions, 170 



Bladder, exploration of, 548 

" last chapter 

Bladder, recurring spasm of from 
contracted meatus, 522 

Bulbous sound, 442 

Bladder, examination of for diag- 
nosis by exploratory operation, 
last chapter 

Chancre, physical characteristics 
of, 29 
" location of, 35 
" induration of, 3-2 
•' without induration, 89 
" irritation of, 95 
" secretion of, 21 
" course and duration of,24 
" inoculability of, 27 
" microscopical appear- 
ance of, 29 
" treatment of, 66-70 
" removal of by excision, 

66, 27 
" termination of, 24 
" healing of, 21 
" of meatus urinaris, 92 
" of lip, 108 
" complicated with herpes 

and phymosis, 101 
" phagedenic form of, 97 
11 simulating epithelioma, 
108 
Chancroid, its nature and treatment, 
18, 207 
*' definition of, 18, 207 

" character of, 31, 207,217 

" usual origin of, 20S 

" secretion of, 208 

history of, 209 
inoculability of. 208 



58o 



INDEX. 



Chancroid, curability of, 209 

varieties of, 228, 208 
abrasion, origin of, 
229 
" mode of development 

of, 226 
" physical appearances 

of, 229 
" progress of, 231 

most frequent localities 

of, 229 
influences modifying, 
235 
" multiple character of, 

231 
cases of, 232, 235 
not dependent on spe- 
cific virus, 228 
reproduction of, 218 
modifications from im- 
planting syphilitic 
elements on its site, 

257 
" excision of, 242 

cauterization of, 242 
non-specific nature of, 

213 
differentiation of from 

chancre, 236 
" diagnosis of, 225 

liability of mistaking 

for chancre, 215 
method of diagnosing 

from chancre, 215 
difficulties in diagnosis 

of, 240 
diagnosis and treatment 

of, 240 
of anus and rectum, 

diagnosis and treat- 
ment of, 255 
diagnosis and treatment 

of urethral, 254 
pustular variety of, 230 
inflammatory, 237 
indurated, 236 
exulcerous form, 256 
phagedenic, 238 
gangrenous, 237 
serpigenous, 238 
bubo of diagnosis and 

treatment of, 250 
diagnosis and treatment 

of bubonic, 250 



Chancroid, diagnosis and treatment 

of sub-preputial, 247 

diagnosis and treatment 

of indurated, 244 

diagnosis and treatment 

of papulo-pustular, 

246 

diagnosis and treatment 

of ecthymatous, 247 

diagnosis and treatment 

of phagedenic, 244 
diagnosis and treatment 
serpigenous, 245 
Circumcision, 26 
Caries of syphilis, 184 
Contagiousness of non-specific pus, 

22 
Canula a chemise, 375 
Cystitis, 413 

" causes of, 413 
" symptoms of, 414 
" treatment of, 414 
'■ case of, 414 
" stricture as a cause of, 416 
Cornil on contagiousness of late le- 
sions, 170 
Cornil on syphiliticosteo-periostitis, 

197- 
Confrontation, evidence by, 53 

Dilating Urethrotome, 447, 469 

Dactylitis syphiltica, 185 

Dick on Gleet, 338 

Diday on contagiousness of late 

lesions, 137 
Dittel on follicular sinuses, 366 

Epididymitis, 390 

manner of occurrence 

of, 390 
causes of, 393 
symptoms of, 390 
" course of, 395 

" treatment of, 396 

results of, 398 
External urethrotomy, description 
of, 37i 
" " management 

of, 372 
Encysted stone in the bladder, case 

of, 544 
Exploratory perineal urethrotomy, 

574 



INDEX. 



581 



Folliculitis, 357 

cases of, 359 
treatment of, 357 
Follicular sinuses, 380 

" relation of to 
stricture, 380 
Founder on self-limited power of 
syphilis, 170 
" on contagiousness of se- 
men, 179 
" on mode of administering 
mercury, 177 



Gonorrhoea, 17, 261 

definition of, 17, 261 
" nature of, 17 

habitat of, 17, 261 
44 specific origin of, 271 
" non-specific, 263 
44 communication of, 262 

" duration of, 284 

by mediate contagion, 

291 
latent, 294 
44 induced by hithiasis, 
288 
44 urethral 
stricture, 267 
44 identical with infantile 

leucorrhcea, 264 
" bacillus of, 277, 300 

44 differential diagnosis 

of, 280 
complications of, 353 
*' abortive treatment of, 

281 
44 futility of internal 

remedies in, 296 
method of treating in 
America, 302 
" method of treating in 

Great Britain, 311 
" systematic treatment 

of, 302 
4 * expectant treatment of, 

315 

treatment of by pur- 
gatives, 319 
" author's experience in 
treatment of without 
specifics, 324 

author's method of 
treating, 300 



Gonorrhoea, method of administer- 
ing injections in, 333 

44 dangers of injections 

in, 330 

" treated by hot water 
retrojections, 306 

14 importance of from a 

medico-legal point of 
view, 265 

44 induced by injections, 
266 

Gleet, 337 

44 definition of, 337 

44 nature of, 336 

44 causes of, 338 

44 degrees of, 348 

44 dependent upon stricture, 

339 
Gumma of the testicle, 158 
Gummy tumor of bone, loss of sub- 
stance with- 
out caries, 
183 
producing 

brain 
symptoms, 

193 

44 of integument and 
cellular tissue, 163 
Goodwillie on removal of necrosed 
bone, 190 

Hereditary syphilis, 204 
Hunterian chancre, 210, 118 
Henle on size of meatus urinarius, 

346 
Harrison on irrigation of the 

urethra, 357 
Hill and Cooper on contagiousness 
of late lesions, 170 
44 " on abortive method 

of treating gon- 
orrhoea, 297 
Hutchinson on syphilitic semen, 178 
44 contagiousness of 

late lesions, 131 
4 4 cerebral syphilis, 202 

Hemorrhage from urethra, method 
of arresting, 463 

Infective germinal material, pro- 
liferation of, 28 



582 



INDEX. 



Induration, significance of, 32 

without ulceration, 87 
the result of inflamma- 
tory action, 52 
Iodide of potassium, means of ad- 
ministration, 164 
Iritis, no 

" treatment of, in 

Lymphatic obstruction, period of, 

139 
Lee on contagiousness of late 

lesions, 131 
Lane on contagiousness of late 

lesions, 131 
Lancereaux on contagiousness of 

late lesions, 137 

Meatus urinarius, division of, 460 
" size of, 346, 422 

Mucous membrane, inflammation 
of, 268 
" patches simulating diph- 
theria, 76 
Mercurial treatment, inability to 

bear, 99 
Milton on treatment of gonorrhoea 
with copaiba, 317 
" the nature of gonorrhoea, 
272 
Mercury, popular prejudice against, 

125 
Masturbation as a cause of urethral 

stricture, 426 
Mireur on contagiousness of semen, 

179 
Mauriac on pericranial periostitis, 
195 

Phymosis, 354 

" treatment of, 355 
Paraphymosis, 355 

treatment of, .355 
Prostatitis, 403 

causes of, 403 
method of occurrence 

of, 402 
symptoms of, 403 
diagnosis of, 404 
termination of, 404 
treatment of, 406 
chronic treatment of, 
410 
Prostatic abscess, 408 



Prostate gland, anatomy of, 402 

" examination of, 405 
Perineal swelling, treatment of, 377 
" significance of, 368 
" crutch, 466 
" urethrotomy, 371 

for explora- 
tion of blad- 
d e r, last 
chapter 
" section, how to control 

hemorrhage in, 375 
" abscess, relation to stric- 
ture, 370 
Psoriasis of tongue, significance of, 

167 
Penis, relation of size of to urethra, 

367 

" circumference of, 441 
Proportionate relation of urethra 

to penis, 367 
Pus, acquired irritant properties of, 



Rectum, examination of, author's 

method, 405 
Reflex neuralgia, 380 
Reflex neuralgia, case of, 380 
Reflex irritations, 487, 490, 491,492, 

498, 504, 511, 518 
Reflex spasm of bladder, 541 
Remedies and remedial agents re- 
ferred to in this volume, and 
their application, 258, 260 
Ricord on chancroid, 211 
Rindfleisch on obstruction of lymph 

channels, 138 
Ricord on inoculability of tertiary 

lesions, 137 
Reflex irritations of the genito- 
urinary tract, 487 
" cause of, 521 
" treatment of, 523 
" cases illustrative 
of, 493 et seq. 

Stricture of urethra, 429 

" causes of, 418, 

421,429,43c* 

" symptoms of, 

430 
" examination for, 342 
" of urethra, diagnosis of„ 
43i 



INDEX. 



533 



Stricture, locality of, 443, 352 

" results of dilatation of, 

458 
'* cure of, by division, 

348 
" operations for, 446 
Strictures of large calibre, defini- 
tion of, 442 
" of small calibre, 467 
Spasmodic stricture, 470, 526 

" symptoms of, 

538 
" cases illustra- 
tive of, 470 
et seq. 
" Bumstead's 
views, 528 
Selling's 
views, 529 
" Erichsen's 

views, 527 
" views of Sir 
Hy. Thomp- 
son, 526 
" " Dittel's views, 

528 
Sounds, bulbous and solid, illustra- 
tion of, 443 
" mode of introduction, 444 
Syphilis, origin of, 20 
" history of, 19 
" definition of, 18 
" nature of material of, 81 
' ' introduction of system into, 

20 
" period of incubation of, 51 
" second incubation of, 34 
" invasion of, 33 
" irritation, period of, 56 
" initial lesion of, 18 
" contagion of, 56 
" inoculability of, 18 
" gland enlargement in, 58 
" contagium of, 18 
" acquirement of, 21 
" course of infective principle 

of, 28 
" inoculation of, through me- 
diate contagion, 36 
" communication by direct 

contact, 35 
" modes of transference of, 

34 
u infection, proof of, 23 



Syphilis, views of its origin, nature 
and composition, 18 
" progress of infection of, 56 
" clinical evidence of, 46 
" early manifestations of, 71 
" active stage of, 44 
" roseola of, 73 
" contagiousness of secre- 
tions in, 101 
" early differential diagnosis 

of, 50 
" prevalence of. 19 
" infection of foetus in, 44 
" of the finger, 38, 185 
' * conveyed bysurgical instru- 
ments, 37 
" clinical case of, 108 
" tobacco and alcohol in, 119 
" in utero, 21 
" falling of hair in, 106 
Syphilides, recurring, papular, 153 
Syphilis of infants, 42, 204 
'• sequelae of, 128 
" from vaccination, 38 
Sequelae of syphilis, non-contagious- 
ness of, 158 
" " " cases illustra- 
tive of, 145 
Syphilis guarantee against commu- 
nicating, 170 
Scrofula simulating syphilis, 179 
Syphilitic spermatozoids, 42 
" ovae, 42 
" nodes, 134 
" rupia, 133 
" ecthyma, 133 
" tumors, 134 
Syphilis, period when marriage is 
allowable in, 121, 175 
" methods of elimination of, 

46, 82-85 
" proportion of cures in, 99- 

100 
" fatty metamorphosis in, 82 
Syphiloma, microscopical composi- 
tion of, 135 
Syphilis, treatment of by fumiga- 
tion, 149 
diet in, 86 
" brain lesions of, 199 
" treatment of in acute stage. 

81 
" innutrition cure of, 82 
" mercury in, 83 



584 



INDEX. 



Syphilitic sequelae, treatment of by 

internal remedies, 189 
Syphilis, duration of treatment of, 

121, 124 

Thompson, Sir Henry, on stricture, 

344, 425 
Thompson's bulbous bougie, 344 
Testicle, anatomy of 392 
Testicle, gumma of, 158 
Tertiary lesions, contagiousness of, 

49 

Urethral Stricture, 418 

detection of 
by urethrameter, 441 
Urethra, description of, 418 
Urethral stricture, definition of, 419 
" congenital, 419 
" mucous membrane, com- 
position of, 333 
Urethral mucous membrane, in- 
flammation of, 334 
Urethra, proportionate relation of 

to penis, 367 
Urethra, irrigation of, 357 
Urethrismus, 470, 527 
Urethrameter, method of using, 441 
Urethrotome, description of, 448 
Urethrotomy, 446 

" utility of, 455 

" safety of, 455 

details of manage- 
ment of, 459 
Urethral fever, 468 



Urethrotomy, after-treatment of, 
466 

Urethral haemorrhage, manage- 
ment of, 463 

Urethrotomy, results of, 448 

for exploration of blad- 
der, 574 

Urethra, calibre of, 442 

Urethral orifice, division of, 460 

Urethral scale, 439 

Urethritis granular, 351 

Urethra, endoscopic examination 
of, 347 

Urethrameter, 342 

Urinary extravasation, 373 

Urinary extravasation, manner of 
occurrence, 377 

Unicists and dualists, 212 

Van Buren and Keyes on the nature 
of gonor- 
rhoea, 273 
" "on abortive 

method of 
treating 
gonorrhoea, 
297 
" "on the causes 

of gleet, 340 
" "on syphilitic 

da c t yl i tis, 
188 
Virchovv on dry caries, 184 
Von Barensprung on contagious- 
ness of late lesions, 137 



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